On My Mind: Poverty


Recently, I waited somewhat impatiently for my turn to have labs drawn. The wait was perhaps 10 minutes. As I sat in the comfortable chair, surrounded by magnificent artwork, my mind drifted to Haiti, where I had been a week before, working in medical clinics that serviced the poor. Some of our patients had walked hours, arrived dehydrated, and then waited hours more for the limited medical care that we could provide. Rarely did anyone seem impatient or anything but grateful.

Haiti is the poorest and one of the most densely populated countries in the Western Hemisphere. When it became the first liberated black nation when its slaves declared independence from France in 1804, France and other nations regarded it with fear and suspicion, and through much of two centuries it has remained isolated.

Under the auspices of Global Health Ministry (GHM), our 12-person medical team traveled hours each day into dirt-floored meeting rooms where we held clinics. GHM comes to Haiti not to provide paternalistic aid, but rather to serve at the request of local NGOs that feel that GHM can enhance their own missions. The region had no running water, electricity, or garbage pickup. Most people ate one meal a day. The roads were mostly dirt and rubble, sometimes running through rivers. There was a pervasive smell of smoke from the charcoal fires that were the main source of fuel. Sometimes there was a smell of burning plastic or sewage. Motorcycles are a major source of public transportation, sometimes carrying five people at once. It is rare to see a helmet, and the youngest child usually rides in the front.

I have written about how and why we detach from reality (bit.ly/OnMyMindDetach), and I like to think that one of the central tenets of psychiatry is that we help people sit calmly with reality, even when it is distressing. I have never found poverty, or the glaring inequalities that are a reality of life in the U.S., as well as in countries like Haiti, to be the main focus of my work with patients. But my children, who grew up in the Martha’s Vineyard public school system, were acutely aware of the differences between the haves and have-nots right here in our home community. They pushed me to be more attuned in general to the needs of people who have less. So last spring when my 20-year-old son, with a newly minted emergency medical technician (EMT) degree, suggested that we go on a medical mission together, and Janet Constantino of Island Counseling, a nurse practitioner and former nun who goes to Haiti every year, suggested that we join her, we jumped at the opportunity. Many other Vineyarders have participated in non-medical missions to Haiti: Nat and Pam Benjamin have started the Sense of Wonder Haiti Fund, bringing supplies and working with other Vineyarders to build boats and houses; Island artist Jeanne Staples started PeaceQuilts, a nonprofit economic development organization which helps women in Haiti establish and develop independent artisan businesses; Margaret Penicaud started the Martha’s Vineyard Fish Farm for Haiti Project, and has been working in Haiti since 1997.
Every day, each one of us saw scores of patients, a high number of whom were suffering from untreated and often undiagnosed hypertension, malaria, worms, dehydration, and urinary tract infections. Because of little access to sunglasses, almost every person over 50 had cataracts. Musculoskeletal pain is simply a way of life. Countless people had sky-high blood pressures; some had been treated in the past, but were unable to afford to continue the antihypertensive medication.

As a psychiatrist, I was struck by the level of trauma that had impacted every life that I encountered. In 2010, an earthquake killed 300,000 people in a country of around 10 million. Another earthquake this past October, along with hurricanes, floods, fires, and gang violence in the capital of Port-au-Prince, took more lives, homes, roads, and livelihoods. One out of five children die by the age of 5. I think of a woman who was hospitalized with an emergency C-section. Though she had left other children at home, she was not permitted to leave the hospital because she was not able to come up with the $140 fee. One woman seen by a colleague came into a clinic believing that she had a dead baby in her because at 50, she had stopped having her menstrual period. Her parents and other elders had all died in natural disasters, and no one had ever taught her about menopause.

As patients waited at the beginning of each day, a translator and I would talk with the assembled crowd about the ways in which the brain copes with overwhelming trauma. We would explain that people who have experienced trauma cope in three main ways. First, the trauma is re-experienced in the form of nightmares and vivid, intrusive thoughts. It is as if the mind is saying, “I am going to play this over and over as if it were yesterday so that you will always be on guard for danger.” The second strategy is to turn off emotionally, become numb and detached from feelings. The third is to be in a constant flight-or-fight mode — the brain is quick to get defensive and angry, there is an exaggerated startle response, sleep is fitful, and there is constant hypervigilance. When we explained that post-traumatic stress disorder is a natural response to unnatural fear, the community nodded, and when we taught breathing exercises and meditative tools to calm the fear, people experienced enormous relief.

We might have had a knee-jerk assumption that our lives are superior to the lives of the poor in Haiti, but as one visiting doctor suggested, “Haitians should be sending medical missions to us. They are more physically fit. They walk everywhere. They don’t smoke or drink or have screen addictions. There is almost no obesity, their families are strong and loving, and their relationships with God are enduring and deep.” The life expectancy in Haiti is not much less than the life expectancy of impoverished Americans.
PTSD was rampant, but though there was considerable major depressive disorder, it did not seem more prevalent than in the U.S. What was striking was how few people described feeling pessimistic about the future, feeling lonely or suicidal. “Do you ever feel lonely?” I would ask, and people would respond, “How could I? God is always with me.” If I asked, “Do you ever feel that the future is lost?” I would receive the reply, “That is in God’s hands, not mine.” Prayer and a relationship with a higher power seemed to protect against despair in a way that I have seldom seen in the U.S. And while many people appear sad and exhausted, they were kind and welcoming, and they smiled readily. As we traveled packed into the back of a 1989 truck, carrying equipment and our pharmacy, children and others often waved and grinned as we passed.

Without screen time, there was plenty of time for our group to talk. One evening, my son Oliver told me about the five love languages — an idea coined by the psychotherapist Gary Chapman. His idea is that the principal ways that humans experience and express love are: 1) receiving gifts, 2) spending quality time, 3) using words of affirmation, 4) performing acts of service, and 5) employing physical touch. Oliver pointed out that in each of our interactions in the clinics, every one of these languages was expressed. The days were arduous and intense, the poverty, loss, and illness often crushingly sad. And yet the way in which our lives touched one another was poignant and beautiful. In each encounter, we listened to each other with reverence, gave each other our time, attention, touch, devotion, trust, and words of appreciation. The days were filled with love and gifts that were all the more striking because of the contrast with all that was missing.

Pam Benjamin has said that she sees herself as the recipient of endless gifts and generosity. “We are all part of the same universe,” she says, and “receiving life’s gifts and channeling them to others makes life fulfilling and meaningful.”

I asked Sister Mary Joe McGinley, the executive director of GHM, to what extent their mission was to impact the lives of the poor and to what extent they were moved by the mission to impact the lives of their volunteers. I was astounded when she said that the missions were of equal importance. Sixty percent of Haitians have absolutely no access to medical care, and yet she saw an equal mission as influencing the worldview of the doctors and nurses and pharmacists who traveled to Haiti. According to Sister Mary Joe, all of the volunteers she brings to Haiti are on a spiritual quest. One of the doctors who traveled with us told me that he felt he got far more from the people of Haiti than he was able to give. I don’t know how any of us can gauge the impact on the lives that we touched. However, I know that I returned with a sense of awe at our shared humanity; gratitude for the love that we shared, and a sense that a new vein of kindness and humility coursed through me. I wonder if it will last.

I hope to return to Haiti, but meanwhile, I find that back here in the “first world,” the need for consumerism and prestige is muted, and a desire to give back is never far away. The team with whom I traveled, including local translators and volunteers, was multicultural, from every social, economic, and educational background. Yet there was never a discordant note. There was instead a mutual respect and warmth that leaves me thinking that doing service with others is a central solution to what ails us, psychically, as human beings. As medical anthropologist and physician Dr. Paul Farmer said, “Poverty is not some accident of nature but the result of historically given and economically driven forces.” There is so much repair work to be done.


Dr. Charles Silberstein is a psychiatrist at Martha’s Vineyard Hospital and Island Counseling Center. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.