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One cannot be truly ready for what the eye sees and the heart feels when you walk amidst the tragedy in Haiti.  And, trying to harden, or steel, the senses of the providers against what they will behold is difficult – perhaps impossible.  All we can do is be absolutely clear in what they will see and absolute in what they will feel. 

 I will attempt to create an outline – listing first what to expect (the challenges), and then some suggestions for getting through it (the mitigation).

 Confusion, almost disorientation, and an overwhelming sense of ‘how can anyone really help’ – these sensations are frequently mentioned by providers when they are debriefed.  Our providers, all trained to work as deployed teams, were familiar with the domestic response.  They understood supply chain variability, living and working in tents, sleeping on cots, using mosquito netting and repellent.  They had trained to work around the dust and dirt of the ground, the never ending sound of the electrical generators, and the limitations of a restricted water supply.  Many had experienced the look their patients would have as the realization of being ill or injured worked through their consciousness and combined with their loss of home, loved ones, and family treasures, heirlooms, and memorabilia passed down through the family as mementos and keepsakes.  What the providers lacked was experience with a supply chain that stretched to another country.   Most had never witnessed piles of boxes and equipment sitting on the ground near a runway – ready for locals with trucks to drive up and pillage.  Security and transportation were never totally ‘assumed’ before – but they always seemed to be there.  This was not the case in Haiti. 

 Whatever you needed in Haiti, you had to either bring with you, or have a well worked out logistics chain back to the States.  Those NGOs that managed to set up healthcare locations without considering this basic truth, quickly found themselves – in the best case – unable to provide anything more than first aid; and in the worst case, they became ‘victims’ themselves – or at least a burden or drain on the limited resources.

 So the first lesson is – be part of a bigger organization that can support you and your mission.  Don’t take 5 or 10 of your buddies and all the supplies you can pack up and charter a flight.  You are going to be more of a problem than a solution.

 Then there is the issue of the incredible sense of isolation of having no where to send (refer) your most serious patients.  The medical infrastructure was in shambles.  Communications to referral centers were frequently not available and when available, simply provided wrong information.  The Haitian Ministry of Health primary building (like almost all the government offices) was in ruins.  The government and medical facilities lost buildings, equipment, supplies, communication, staff members and, for those survivors, family members.  The fact that they could function at any level was a testament to their courage and dedication. 

 The US Navy and the US Department of Health & Human Services attempted to survey and catalog the facilities that were still able to provide care and both the level of that care and availability of specialty care.  However, the results were conflicting and seemed to change daily or even hourly.  The typical referral system with which US providers had experience, i.e., call a facility to get an accepting physician, simply did not work.  What eventually did work was to work closely with a limited number of facilities, get the cell phone numbers of a few specialty providers, and call them directly.

 Developing a referral system, working that system, and actually transferring patients (which included obtaining vehicles, drivers, and security) requires a fairly well connected organization.  Again, my emphasis on not trying to do it small.  Be somehow connected to a bigger organization with, hopefully, international backing – including a referral pathway to another country.

 Success, even limited success, required organizational support, money, transportation, security, and a referral system that you help create and manage.  Then there is the issue of ‘standards of care’.

For the local physicians and many of the NGOs, because of the environment, the lack of supplies, the absence of a referral system, poor communications, and absent or inadequate security and transportation, the standard of care that providers were used to was non-existent.  Providers cannot rely on simply transferring patients to other countries – including the United States.  One becomes inundated with patients that should be treated with the latest generation of antibiotics, yet those antibiotics are nowhere to be found.  The patient needs an ophthalmic referral for globe laceration, yet you can find no one who knows anyone who is an ophthalmologist – at least with equipment and supplies.  The infant presents with ‘failure to thrive’.  You suspect congenital heart disease but have no ultrasound.  Or perhaps worse, you get an ultrasound and find Tetralogy of Fallot – but have absolutely no way to treat and therefore are faced with telling the mother that, without surgery, her child will unlikely live pass their 20th birthday.

 In an environment of severe trauma, e.g., a post earthquake scenario, amputations were commonplace because skin grafts were not available.  Infection, if present, was treated with massive doses of whatever antibiotic you happened to be able to obtain.  Kidney failure from crushed muscles was simply not treatable.

 So how does one cope with working in an environment of standards of care that are remarkably different (worse) than what one is used to?   Here is what we saw that reflected the inability to deal effectively.  We saw anger to the point of rage – followed by, or preceded by, incredible frustration.  We witnessed providers threatening to call the media in an attempt to change their environment.  Providers packed up and left.  Some cried. 

 How would anyone prepare for those feelings?

 Again, be part of a bigger system.  Stay for no longer than two weeks, and then rotate out for at least a month.  Be healthy before you decide to deploy into the environment.  Get your immunizations and sufficient routine medication for yourself – and don’t forget to take them while deployed.  Have an inviolate work/rest cycle.  It was hot – stay hydrated.  It was dirty – do your best to stay clean.  If you have significant health issues and/or are obese or have mobility challenges (wheelchair, crutches, even a cane), do not deploy.  Finally, as you redeploy (return home) you must have an opportunity to talk to a counselor about what you’ve seen and how you feel about it.  I found that I felt incredibly guilty that I was returning home when there was so much to still accomplish.

 In summary, be healthy or don’t go.  Be part of a large, well supported system, or don’t go.  Return home after two weeks and do not return for at least a month.  Be as mentally prepared as you possibly can to have patients that, ‘back home’ you’d have no problem treating – but in Haiti you’ll let them die or remove their limb or eye, or leave them tremendously disfigured.  And, lastly, participate in a debriefing upon departing that permits you to examine your feelings.

News from Haiti

February 2, 2010 was my birthday — and it marked my second week in Haiti as the Senior Representative of the Secretary HHS.  It was an incredible opportunity to see both the tremendous outpouring of response; and our HHS assets who, as of February 3, HHS has assisted 24,570 patients in Haiti and in whom I am incredibly proud!

But, the most memorable, yet heart wrenching, event was to walk among the men, women, and children of an Internally Displaced Person’s (IDP) camp.  The one I visited was not sanctioned by the Government of Haiti, but a spontaneous accumulation of an estimated over 200,000 Haitians.   It was below the (formerly plush) golf resort of Petionville which is situated on top of a hill, south of the city of Port-au-Prince.  The US Army has occupied the facility and HHS established a 35 person medical team (Disaster Medical Assistance Team – DMAT).  They saw literally 100’s of patients every day!  “Strike Teams” of 4 to 6 roved through the IDP camp daily to seek out the very sick & injured.  Gangrene, open wounds, fractured bones, women in labor either too early or way past due, or children with a variety of infectious disease – EACH DAY!!!

Internally Displaced Persons (IDP) Camp

Dozens lined up and circled a kiosk where a physician sat like Santa Claus chatting with a mother who held a little girl of perhaps 4 or 5 who lay limp across her lap.  The little girls eyes revealed were as the Japanese would describe as “Dame” – “the emptiness of the eye of a horse”.  No expectation of relief, only that soul grabbing gaze of one who had given up.

IDP Camp lining up for doctor

Yet, I witnessed little boys who had constructed small kites from garbage who were flying them successfully and competing with each other. 

IDP Camp boy made kite from trash - flew very well

 I saw a little boy pounding on a can with a stick while two little girls danced to his makeshift music.  As I passed by with my camera, children were like children everywhere – posing for the camera and smiling with all the innocence of youth.  Their mothers were busy trying to wash or nurse infants, make food, or wash clothes in little basins of non-potable water.

There were entrepreneur vendors – food (cooked and raw), clothing, soap, even silver jewelry!  The problem is that there seems to be no cash for such items. 

IDP Camp food for sale

But in all that I witnessed, the children will forever haunt my dreams.  I will never forget.

Children of the IDP Camp

Ms. Diana Weaver, Senior Public Affairs Specialist, Northeast Region U.S. Fish and Wildlife Service, contacted me to use one of my photographs of Elk River, West Virginia on their website.  It supports endangered species.

If you click on the photo, you will be taken to the website!

The actual photo is here:

Elk River, Elkhurst, West Virginia

Elk River, Elkhurst, West Virginia

The photo was taken from a very old and condemned swinging bridge.  Years ago I actually drove my car across this bridge – now one hesitates to walk on it!

Elkhurst Swinging Bridge on Elk River

Elkhurst Swinging Bridge on Elk River

One of the more technical things one can do to their digital camera is modify it to either expand or limit the wavelength that is recorded.  Although this can be a do-it-yourself project, there are companies that will do this and guarantee their work.

Modifications can be for ultra violet, infra red, or astrophotography.   Here, for example, is a movie that William Castleman made with his camera.   You can read how he made it on his website.  Basically, he used his Canon EOS-5D (AA screen modified to record hydrogen alpha at 656 nm) to record this and then assembled it in Quicktime Pro (available for either Apple or Windows computers).  Editing/assembly was with Sony Vegas Movie Studio 9.  Incredible work!

There is much published online regarding Infrared (IR) photography.  Photo Extremist has a well written article on The Complete Color Infrared (IR) Tutorial Guide Walkthrough‘.  You can see a variety of both color and black & white work there – including this photo:

Gold is the Sky

Much more common is the alteration of the digital camera for Infrared work.  LifePixel receives great reviews for a variety of conversions (as well as repair of scratched sensors!).  They have excellent discussions and photographs from their work on Flickr in the group ‘Converted Digital Infrared Cameras‘.  Other conversion locations include Spencer’s Camera & Conversion.   Conversion for a Nikon Digital SLR could run you $325 to $375.    Also, Spencer’s has cameras for sell that are already converted.  A Nikon D70, body only, with full conversion runs $600.  However, it does open another world of photography!  Check out these Flickr groups:  Digital Infrared and D300 Infrared.

For the more ‘technical reader’, Luminous Landscape has posted an in depth discussion here {although the work on that site was done with a modified Cannon D20}.  Luminous Landscape, by the way, is a great source of photography information.

One might ask, “Does this ‘artform’ make be a better photograher?”.  Not necessarily.  I would argue that someone who takes poor ‘regular’ photos, will take poor IR photos!  However, Alexandra Morrison, the Canadian Photographic ‘Artist of the Year 2009′, says it does!  I invite you to see her blog, and specifically her article titled ‘Dedicated Infrared Digital Camera Conversions: Why it makes you a better Photographer‘.

For me, I love photographic experimentation and intend to try it!

How I traveled thus far.

The Early Years

I began my photographic experience with a Argus C-3. This was a range-finder camera and took great pictures!
In 1969 I purchased my first Single Lens Reflex (SLR) camera, a Pentax H1A. That camera served me very well as I experimented with darkroom techniques, traveled throughout Europe, and began producing photographic art.

In 1975, I traded my Pentax (and all of my lenses) in for an Olympus OM-1. I added a second camera body and then a third body, the Olympus OM-2. The Olympus system was simply wonderful! I carried the Olympus to several countries and then moved to Guam.

Moving to Nikon

A very good friend on Guam introduced me to his Nikon system. Before I knew it, I was the proud owner of a Nikon 8008 and several Nikon lenses.
As digital photography improved, and passed the 6 megapixel limit, digital photographs were finally to the quality of 35mm film cameras. I had already begun to have my negatives scanned and was using Photoshop to prepare my photos for printing and presentation. So, in 2004, I moved to the Nikon D70. The D70 boasted a 6.1 megapixel sensor. It provided excellent photographs — and was compatible with my Nikon lenses!

My Equipment Today

Finally, I ordered a Nikon D300 in July 2007. I was one of the first to order and had to wait until Thanksgiving, 2007 to receive it!
Technically, the D300 is incredible — as for quality of photographs, it’s difficult to beat! It offers the photographer a 12.3 megapixel DX-format CMOS sensor, as well as the choice of selecting bit-depths at 12-bit (4,096 tones) or 14-bit (16,384 tones), both yielding incredible image quality through a full 16-bit processing pipeline. Furthermore, the D300 enables photographers to choose smaller files at faster operating speeds, as opposed to larger files with smoother tonal gradations as slower operating speeds.

Reproducing Subtle Tones in the Highlights & Detail in the Shadows

Another photographic breakthrough occurred, the introduction of High Dynamic Range (HDR) photography for the average user. Although introduced in the 1930′s, through today’s software and the use of high-end digital cameras, HDR permits the photographer to capture a much wider range of light than normal photographs display. The photographer can choose (via various software, e.g. Photomatix or Dynamic Photo HDR) to produce a ‘normal’ photo with extended dynamic range — or photographs that look ‘extreme’ and almost as though they were drawn by graphic artists. For a nice article on HDR, please click here.

Or here for a Pop Photo article on ‘how to’.

So this is my first attempt to start my blog.  I intend to document my journey through photography.

Please feel free to contact me at my email:  R.Tom.Sizemore@1972.usna.com

Also, I invite you to check out my website at:  Optimal Light Photography

And/or, check out my Flickr photos at:  Photos on Flickr

Here is an example of my photography.  This photo was taken with a Nikon D70 at my parent’s farm in Clay, West Virginia.  My father has an apple orchard and there had been a fairly decent snow storm.

Apple Trees in Snow # 1-  11x24

And, here is an example of some architectural work – a building in Washington, DC.

HDR tonemapped

And, finally, here is the Memorial Bridge in Washington, DC.  I took this picture around 5 AM one cold morning!

mem bridge.jpg

I hope you enjoy my photographs.

Sincerely,

Tom

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