By Way of Home, and By Way of St. Kitts
What the Load Teaches
Field Notes Series: The Soft Side
Entry #4 of 6
Disclaimer
Field Notes reflect the editorial analysis and personal reflection of the Managing Editor, informed by direct professional experience across Caribbean healthcare systems. These observations are the author’s own and do not represent the official positions of any government, institution, or commercial partner.
There are chapters in a life that resist clean description. Not because nothing happened — everything happened — but because what happened was so layered, so simultaneous, so compressed into a narrow corridor of years, that the only honest way to render it is to sit with the fullness of it rather than reduce it to a sequence.
The years between 2015 and 2021 were that kind of chapter. Two daughters. Two hurricanes. A pandemic. A healthcare facility opened against the logic of the moment. A father’s funeral. And a family, finally reunited, in the Bahamas in April 2021, after twelve months that tested every form of resilience the preceding years had built.
This piece covers that ground. It is longer than the others in this series because the ground demands it.
The capacity to hold multiple things simultaneously is not a gift you are born with. It is a muscle. It develops under load.
2015 — The Winding Down
My husband and I were winding down the BVI base in 2015. Our first daughter arrived in May 2015, his work took him to the U.S. Virgin Islands. We split our time between North Carolina and St. Thomas, carrying a life across three addresses, two territories, and an ocean, the way people do when the work and the family and the geography of the Caribbean refuse to sit still long enough to be managed neatly.
The work continued. It always continued. The pioneering medical travel and accreditation work, the regional advisory work, the global reach of what had been built across the BVI years — none of it paused for the personal. That is not a complaint. It is simply the texture of a life lived at this intersection. You carry what needs to be carried. You show up where you are needed. You find, over time, that the capacity to hold multiple things simultaneously is not a gift you are born with. It is a muscle. It develops under load.
You carry what needs to be carried. You show up where you are needed. The work does not pause for the personal.
September 2017 — The Storm
In 2017, I returned from Thailand — work had taken me there, as it took me to many places between 2015 through 2017 —I landed in St. Thomas. The Caribbean was watching the Atlantic. A storm was forming that meteorologists were describing in terms that people who live in hurricane country learn to take seriously. Its name was Irma.
Due to being more than 7 months pregnant with our second daugther, I left St. Thomas Friday, September 1 as a precaution.
On September 6, 2017, Hurricane Irma made landfall across the northern Caribbean as a Category 5 storm with sustained winds of 185 miles per hour — one of the most powerful Atlantic hurricanes in recorded history. The U.S. Virgin Islands took a direct hit. The British Virgin Islands, where I had lived for nearly four years, was devastated. Two weeks later, Hurricane Maria struck. The region I had spent the better part of a decade working in, learning from, and building a life inside was, in the space of a fortnight, changed in ways that would take years to measure and longer to repair.
My husband did not return home for over a month. The immediate hours after Irma passed were emotionally taxing – I received a call from an unknown Ohio phone number – it was my husband using someone else’s phone to let me know he was ok. The next was attempting to figure out how my family fared in the BVI, thankfully, everyone was ok despite so much physical damage to homes, roads, and utilities.
He was working in St. Thomas in the immediate aftermath, in the grinding, physical, human work of helping a place begin to reconstitute itself after a catastrophe. Communication was intermittent. Travel in and out was only through government assets. The distance was absolute in the way that only a destroyed infrastructure can make distance absolute — not miles, but the absence of the ordinary means of crossing them.
There is a thread that runs through our life together that I have noticed over the years and never quite been able to explain to people who have not lived something similar. Hurricanes — not as metaphor, but as literal events that have shaped the geography of our family, our work, and our decisions in ways that feel, in retrospect, almost improbable. The BVI before Irma. St. Thomas during Irma. The Bahamas after Dorian. When you choose to make your life in the Caribbean, you choose the storms as well. We knew that. It was part of the terms.
Our second daughter was born in November. The Caribbean was rebuilding. The work was continuing. And the commitment that had been forming since Antigua — to the region, to its public health systems, to the people for whom the quality of care was not a matter of preference but of what existed — was not weakened by those months. It was deepened by them.
The 2017 storms did not just destroy infrastructure. They exposed it. They revealed, more clearly than any policy paper or regional report, which systems held and which collapsed, which communities had been built to withstand, and which had been built to hope. For those of us who work in health systems — who spend our professional lives thinking about the human infrastructure inside institutions — 2017 was a reckoning. It showed what the decades of work had and had not produced. What remained when everything else was stripped away.
The storms did not just destroy infrastructure. They exposed it. They showed what remained when everything else was stripped away.
2018 — St. Kitts and Nevis: A Project That Was Real
By 2018, the in-between was ending. An opportunity arrived in St. Kitts and Nevis — a Chief Operating Officer role with a healthcare real estate development company licensed in the Federation. The project was serious. Well-funded, with a credible group of people behind it, and a vision that was architecturally and operationally ambitious in ways that distinguished it from the landscape of ideas that circulate in the Caribbean health space.
I want to pause on that distinction, because it matters. When you spend close to a decade working across the region, you encounter a great many projects. Infrastructure initiatives. Public-private partnerships. Investment proposals for new facilities, new services, new models of care. Some of them are genuinely serious. Many are not. The difference between a project and a presentation is not always visible at the outset — it reveals itself over time, through the accumulation of decisions made and resources committed and obstacles encountered and how a team responds when the path becomes difficult.
This project was real. The first phase — an outpatient facility — was the evidence of that. It was built. It opened.
The difference between a project and a presentation reveals itself over time — through decisions made, resources committed, and how a team responds when the path becomes difficult.
February 2020 — The Pandemic Arrives
On February 15, 2020, I arrived in St. Kitts and Nevis with my two daughters. My husband was in the Abacos of the Bahamas, where he had been working since Hurricane Dorian devastated parts of the archipelago in September 2019 — another storm, another reconstruction, another chapter in the thread that hurricanes have woven through our life. The plan was to move between St. Kitts and the Bahamas around school breaks, maintaining the family across two islands while the work in both places continued.
In late March 2020, the borders closed.
The world was, by then, in the early weeks of understanding what Covid-19 was going to require of it. Countries were making decisions in real time, with incomplete information, about how to protect populations that had no immunity to a virus no one had encountered before. Small island developing states across the Caribbean moved quickly — closing borders, restricting movement, implementing measures that were, in many cases, more decisive and more effective than those of much larger nations. St. Kitts and Nevis was among them.
The borders closed. My husband remained in the Bahamas. My daughters and I remained in St. Kitts. The twelve months that followed were among the most intense of my professional life — and among the most clarifying.
Small island states moved quickly — closing borders, restricting movement, making decisions with incomplete information in the interest of populations that could not afford to wait.
August 2020 — Opening a Healthcare Facility During a Pandemic
In August 2020, the outpatient facility opened.
I want to sit with that for a moment, because I believe it is not fully appreciated how improbable that was or how unnecessary it was. Across the western hemisphere, healthcare systems were under conditions of extraordinary strain. Elective services had been suspended in most jurisdictions. The global conversation about healthcare was almost entirely focused on acute care — on ICU capacity, on ventilator supply, on the management of a respiratory illness that was overwhelming hospitals in ways that had not been seen in a generation. Opening a new private outpatient facility, in a small island federation, offering elective services, in August 2020, was an act of considerable institutional determination.
It was also, I believe, an act of faith in what the region could sustain. St. Kitts and Nevis had managed the pandemic with remarkable discipline. The federation’s case numbers were, by global standards, extraordinarily low. The public health response had been serious, consistent, and effective. In that context — a protected environment, a population that had been carefully shielded, a health system that had not been overwhelmed — the opening of a new outpatient facility was not reckless. It was a statement about continuity. About the long work of building health infrastructure that cannot pause indefinitely because a global crisis has made the timing difficult.
I was, for all practical purposes, the lead operational executive for the company in the country. The project continued because the commitment to it continued — because the team believed in what was being built and understood that the work of building health capacity in a small island state is precisely the kind of work that must outlast the moment of maximum difficulty.
The second phase of the project — an ambulatory surgical facility planned for a luxury residential development on the southeast peninsula of St. Kitts — was a different matter. Architecturally and operationally, what was planned would have meaningfully shifted the landscape of outpatient and ambulatory surgical care in the Caribbean. It did not come to fruition. The financing model that the project depended upon could not withstand the compounding uncertainties of a global pandemic. The assumptions that had made the numbers work in 2018 and 2019 did not survive 2020. That is not a failure of vision or commitment. It is what extreme and sustained economic disruption does to financing structures that require a stable set of conditions to materialize.
I carry that chapter with the mixture of pride and grief that belongs to things that were real, that mattered, and that did not fully arrive. The outpatient facility stands. The surgical centre does not. Both are part of what St. Kitts taught me.
Some things that are real, that matter, and that carry the full weight of serious intention — do not fully arrive. That is its own kind of grief, and its own kind of lesson.
2020–2021 — Inside the Bubble
St. Kitts and Nevis during the pandemic was, in many respects, a remarkable place to be. A federation of fewer than 70,000 people, governed with unusual discipline and clarity during a period of global chaos. When I left in March 2021, there had been less than 50 confirmed cases. In a world where the numbers in larger countries were measured in the tens of millions, St. Kitts and Nevis had, through a combination of decisive leadership, geographic advantage, and population compliance, held the virus almost entirely at bay.
Living inside that bubble was odd in ways that are difficult to fully articulate. The island was calm. The community was intact. The ordinary rhythms of life — the market, the school run, the conversations between neighbors — continued in ways that were, by the standards of most of the world in 2020, almost surreal. And yet the world outside was not invisible. It arrived through screens, through the news, through the phone calls that connected the bubble to everywhere it was not.
My father was in a memory care unit in the United States. My mother had longstanding respiratory challenges that made her acutely vulnerable to a respiratory pandemic. I was in St. Kitts, in a protected environment, watching from inside a calm that I knew was not the experience of the people I loved most. That tension — the guilt of safety, the helplessness of distance, the knowledge that the border that was keeping the virus out was also keeping me in — is something I carry still.
When you work in healthcare, you understand, in a way that is not purely intellectual, what a pandemic requires. You understand the systems under strain. You understand what it means when a health system approaches its limits. You understand, because you have spent years thinking about the human infrastructure inside institutions, what it costs the people who are inside those institutions — the clinical staff, the administrators, the cleaners and the porters and the people answering the phone at 2 in the morning — to sustain a response over months and then years. The pandemic was not abstract to me. It was the amplification of everything I had spent seventeen years trying to understand.
I did what I could, from where I was. That has always been the answer. You do what you can, wherever you are. The calling does not ask for optimal conditions. It asks for presence and commitment, and you bring what you have.
The calling does not ask for optimal conditions. It asks for presence and commitment. You bring what you have, from wherever you are.
March–April 2021 — The Return
On March 3, 2021, I left St. Kitts and Nevis and returned to the United States to attend my father’s funeral.
There is not much more to say about that than what it is. A parent’s death, arriving at the end of a year in which distance had already made the ordinary forms of care and presence impossible. The grief of losing someone in a memory care unit, across a closed border, without the ability to be there in the ways that matter — and then the particular quality of a grief that arrives after a long anticipation, when you have had months to understand that it is coming and discover, when it arrives, that understanding does not diminish it.
I left St. Kitts with what I had built there, and what I had lost, and what the pandemic year had confirmed in me — about the region, about the work, about what public health systems are for and what they require of the people who build them. I left with more badges on my jacket, as I think of it. More experiences and observations organized into the kind of understanding that only comes from having been inside something difficult and come through it.
In April 2021, I joined my husband in the Bahamas. After twelve months apart — separated by closed borders, by the requirements of the work, by the unpredictable geography of a pandemic — our family was together again. Our reunion was quiet in the way that the restoration of ordinary life is always quiet, after the extraordinary has demanded everything.
The work continued. It always continues. But there are moments when what the work has cost, and what it has given, and what it has prepared you for, come into focus simultaneously. April 2021 in the Bahamas was one of those moments.
The next chapter was already forming. Another daughter on the way. A phone call not yet made. A question not yet asked. A chain of connections that would lead, eventually, to a publication you are reading now.
But that comes later. First, there was the Bahamas. There was the family, together. There was the quiet after the load — which is, in its own way, the beginning of everything that follows.
About This Series
The Soft Side is a seven-part Field Notes series tracing seventeen years of health system work across the Caribbean — and the people, places, and lessons that shaped it. New parts publish each Sunday.
Coming next Sunday:
Part 5 — By Way of Montserrat: The Question That Changed Everything
September 2021. A phone call to the Head of a Programme Management Office. An interview process. A hire. What public sector work demands that private work does not — and the chain that one question set in motion.
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