Gracia Etienne, MD, PhD: He Lives in Two Worlds

Gracia Etienne, M.D.

As he carefully cut the sutures the scissors snapped in half. They were designed as disposable instruments but they were sterilized and reused many times and the metal deteriorated. Seeing this, the usually sturdy surgeon “cried like a baby.” Sure, he noted, even in this third world country of his childhood, such one-time-use tools would be disposed of. But, “at one time.”   

(If you prefer, you can listen a reading of the story here.)

When he returned to York from the medical mission to a northern part of Haiti he asked the OR nurses to let him sift through the surgical “waste” before it was discarded. Items that have no value in one place may be prized elsewhere.    

Even now, more than ten years after that 2008 mission,  Dr. Gracia Etienne told me that he is moved when he thinks about the simple surgical tool that fell apart in his hands. 

Before that, he had been content to go on a volunteer medical mission every now and then. But was that enough for his terribly suffering country? To do more, he said quietly, he “needed a sign.”  

On Tuesday, January 12, 2010, at exactly 4:53 p.m. local time, a catastrophic magnitude 7.0 earthquake occurred 25 kilometers west-south-west of Port-au-Prince. Buildings crumbled and many thousands of Haitians lost their lives. “Okay,” he said, “I wanted a sign from above, but that was too big!”  

Map of the 2010 earthquake (www.britannica.com)

A week later, with plenty of medical supplies in hand, he was in Haiti trying to help. When he returned a bit later he wondered if he could do more. He decided to start a small orthopedic clinic. 

His boyhood home was damaged by the quake, with visible fissures in the walls, but it seemed safe enough for temporary use, and his father offered it to him. Dr. Etienne’s bedroom served as the OR, the living room was the recovery area, and the porch was the waiting room. “We did what we had to do,” he said. 

His father, a successful rice farmer, then saw what was happening and told his son that the people, his people, needed what he was offering. The grateful surgeon perceived this, too, and admitted that he was “hooked” as he gently ministered to the wounded. 

But before we go on with the rest of that part of the story we need to go back to the beginning. So...   

“How did you become a doctor?” I asked Dr. Gracia Etienne as he sat next to his wife Manotte in my living room.

“By default,” he simply said. In Haiti, he noted, there were three good options after finishing secondary school. You could go into medicine, you could be an engineer, or you could go into agriculture. The smartest students chose to attend medical school. 

He was bright, sure, but he was young and undecided about what to do with his life. So those who knew him best “pushed” Grassi into medicine. And once he started on that path he “fell in love with it” and “there was no going back.”  

He finished the first year and a half of medical school and was “living the Haitian dream” and had direction. But this was 1986 and the country was experiencing a period of severe economic strain. Tourism was affected by HIV, and the entire Creole pig population (the source of much of individual Haitian's income) was sacrificed (after U.S. pressure) due to feared spread of the African swine flu virus.  

Haiti's perfectly adapted Creole pig (from "The Star") 

There were violent strikes and political uprisings, and the ruthless and corrupt dictator “Baby Doc” Duvalier was forced into exile. Making things even worse, there was the beginning of a crippling embargo.  After awhile Gracia “couldn’t take it anymore.”

So in February 1988, at age 21, he put everything he had into two suitcases and moved to the States; he landed in New Jersey where he was “totally alone.” With only a visitor’s visa, he could not continue his education as planned and it took a year to get a permanent visa and a Social Security number so he could move on. During that difficult time between the two visas he “did a lot of crying”. But he was determined. He drove a taxi, first in New York, and then in New Jersey, to save up for college. 

With the needed documents finally secured, Gracia then studied biology at Seton Hall, signing up for as many credits per semester as was allowed. Halfway through his second year, he took the test for medical school admission (the dreaded MCAT)... for practice. He said he did “extremely well.” 

So, after only two years of college, he then decided to apply to medical school early... for practice. Unexpectedly, he was granted four personal interviews. 

And he was handed a letter of acceptance and a scholarship to Penn State Hershey (pause for this)...at the end of their interview. They then gave him a train ticket to get back to Jersey so he could avoid another tiring bus ride (His sinuous trip to Hershey from East Orange had been through the night to get him to the early morning interview on time.) 

“Were you surprised?” I asked.

“Yes, I was, “ he humbly replied. Dr. Etienne said he does not think he is smarter or more polite than the guy next door. Or that he behaves any better. You see, he has a very strong religious faith (grounded initially in Catholicism and now Pentecostalism) and he believes the hand of God guides him. 

So he entered medical school here without a bachelor’s degree in anything.  He had cautiously waited until then to tell his father “the truth.” That he was not actually planning to come back to Haiti, as he had led his family to believe. (His older brother was set to enter medical school in the U.S. but didn't go.)

Haiti remained under the economic embargo (that was in place for 14 years), and without the ability to trade the high-quality local rice with the rest of the world, his father’s business started to fail. Gracia needed to help. So, for nearly two years, as he studied medicine full-time during the day he worked in the Hershey sleep lab almost full-time at night to be able to send money home. 

He admitted that as he manned the sleep lab he could study, yes, but that he often fell fast asleep, a no-no. (This reminded me of the famous scene toward the end of one of my husband’s favorite movies, "Dr. Strangelove": Peter Sellers, as the president, trying to break up the confrontation between the American general and the Russian ambassador, demands firmly, “Gentlemen, you can’t fight in here! This is the war room!” As in, “You can’t sleep in here, this is the sleep lab!”)  

War room scene from Dr. Strangelove (from latimes)

Anyway, during medical school, Gracia had time to volunteer at a nursing home (maybe Haitian days are longer than 24 hours, I just don’t know). And it was here, as he saw many gratifying recoveries after hip surgery, that he “fell in love with the restoration of function.” And he decided to “go for it.” 

He first thought about being a trauma surgeon but was put off by “the lifestyle” (see Dr. Nikhilesh Agarwal's story, “Trauma Surgeon without his Mask”) and chose orthopedics instead. 

He did a five-year ortho residency at Downstate Medical Center in New York and he “clicked” with prominent spinal surgeon Dr. Paul Brisson. They got along well. They bantered in French in the OR and got away with saying not-nice things about the clueless others in the room. Even as a second-year resident, Dr. Etienne's technical skills allowed him to do major surgeries. He enjoyed the work.

Paul Brisson, M.D.

After New York, he went to Johns Hopkins for a fellowship in adult reconstruction. He then stayed on in academics for a few more years as a clinical professor.  Dr. Etienne operated on patients at Sinai Hospital In Northwest Baltimore (that was founded in 1866 as the Hebrew Hospital and Asylum), published a few scientific papers on osteonecrosis, and taught the orthopedic residents. 

But he eventually looked around, and deep inside himself, and wondered, “What am I doing here?” He told me that this activity was not fulfilling; that he felt he was “faking.” He was unhappy, and the residents he worked with sensed that. A few of them were rotating through from the Memorial Hospital in York and they told him about the OSS (Orthopedic and Spine Specialists) group. Gracia was interested. He spoke with Dr. Vince Butera and Dr. Brian Bixler about joining the practice and, after five years in Baltimore, he left and moved to York. He’s been with OSS since.

He does shoulder surgery, hip procedures, and a lot of total knees. “The hip and knee replacements are two of the most successful procedures we offer now,” said Dr. Etienne. He said that we should try to protect our knees from “micro-injury” since this is the cause of “most of the osteoarthritis we are dealing with.” Running is a major culprit, and “there’s no need for it (as we get older).”  Being overweight and having a knee deformity are also important risk factors for the development and progression of knee arthritis.

The non-surgical treatment of osteoarthritis of the knees is intended only to relieve pain; no medical treatment, no treatment at all, has been shown to alter the course of the disease. 

What can be done before the surgeon takes over? The authors of the 2013 guideline from the American Academy of Orthopaedic Surgeons favored the use of oral NSAIDS (or nonsteroidal anti-inflammatory drugs) such as ibuprofen or naproxen, topical NSAIDS, and the weak opioid and serotonin/norepinephrine-active drug tramadol, for control of pain. They did not argue either for or against acetaminophen, opiates, or steroid injections. But they recommended against the use of glucosamine or chondroitin sulfate or even hyaluronic acid (Synvisc) injections.

When these symptomatic treatments are not enough to ease the pain the orthopedic surgeon can, in Dr. Etienne’s words, “offer the solution.”   The success rate of surgery is about 90% and the materials of the prosthetics have improved so much recently, he said, that total knee replacements now last at least twenty years.
 

Total knee prosthesis (medlineplus)

As I listened to this gentleman from Haiti, the only country established by a slave revolt, I wondered what his experience has been with respect to race and racism here. So I asked him.

"I can sense (‘institutional’ racism) and I can easily brush it off,” he said. But he noted that it is much harder to do that when he, himself, is the target of overt bigotry. 

He told me that when he was in Long Island tending to a local man who had broken his tibia the patient suddenly demanded, ”Get your (insert the skin color of your choice here) hands off of me!” Reacting swiftly, and with purpose, Dr. Etienne quietly asked the nurses to leave the room. 

He then firmly addressed the belligerent patient and said, “You are here to see me. I am not here to see you. If you need my help I am going to help you. But you cannot disrespect me.” He then took hold of the man’s misshapen leg with both hands and reduced the fracture; the patient winced but did not utter a single word.  

As I heard this I felt a squeezing sensation in my chest. I was ashamed, and I apologized to Gracia. I was saddened, knowing that we have not moved beyond our dark national history of racism. That more than 55 years after Dr. King’s speech, we are not able to judge people “by the content of their character.”

March on Washington for Jobs and Freedom 1963

Anyway, where were we? Let’s continue in York. 

It turns out that Dr. Etienne’s young son went to a church-based school and when Gracia met the very busy couple who ran it, the Revs. Wendell and Juanita Burden, he “fell in love” with them. Night and day, weekdays and weekends, they have been taking care of their “relational” Pentecostal congregation located in a poor section of the city. Dr. Etienne joined them, studied, and is now an ordained pastor in their church. And (in his spare time, I assume) the Reverend Dr. Etienne hopes to unburden the Burdens.

Meanwhile, to give back to his people (who have still not recovered from the 2010 earthquake and were later hit by hurricane Matthew in 2016), Dr. Etienne, with his wife, founded the non-profit foundation MIVO in 2009 (the website can be found here). They built and then added on to the small outpatient hospital since then. Their goal is to “bring orthopedic care to the underprivileged in Haiti in the name of Jesus.” 

This is Gracia’s passionate calling as he arranges week-long missions to the hospital every three months and brings a volunteer medical team of about a dozen to join him. 

A few reliable Haitian nurses manage the hospital in his absence and stay in touch with him by phone for difficult cases. When he and the others are expected to be in attendance the people line up all the way to the road (the hospital is set back a good bit) and wait for hours. 

The MIVO orthopedic hospital in L'Estere, Haiti (MIVO) 

Dr. Etienne and his colleagues were scheduled to have a session this month but the situation in L’Estere and Port-au-Prince is currently too dangerous.  According to the New York Times, “violence and economic stagnation stemming from a clash between the president and the opposition are worse than anything (the Haitians) have ever experienced.”  Thousands of protesters are filling the streets, seeking to chase out another corrupt leader. They are blocking the main roads and creating chaos and mayhem. 

So, as this is being written (late October 2019), Dr. Gracia Etienne is stuck in the Dominican Republic, the country making up the western half of the island of Hispaniola that is shared with Haiti. He still hopes to provide his simple orthopedic clinic with much-needed surgical supplies, including plenty of “disposable” scissors, and to return there himself when it is safe. 

But the immediate future does not look promising. One may need to rely on faith. 

Please stay tuned.

Or in French: S'il vous plaît restez à l'écoute.

And in Haitian creole: Tanpri rete an kontak.


References:

1.  Isaac, Harold, and Kohut, Merideth. “All but Poverty and Despair is at a Halt in Haiti.” New York Times. October 21, 2019. Section A, page 1.

2.  King, Martin Luther 1963: archives.gov/files/press/exhibits/dream-speech.pdf  

3.  Lozada, Carlos. "Osteoarthritis." Medscape. Updated 10/21/19.


Recommended Reading:

1.  Allport, Gordon W. The Individual and His Religion. The MacMillan Company. New York, 1950.

York Water Company Reservoir Park 10/27/19 (SC)

Anita Cherry