Cholera, Public Health

Improving Haiti’s Healthcare System

Haiti’s public hospitals serving the country’s poorest have gone on strike twice in the last 12 months, in the midst of a deadly epidemic. The media was still reporting on the distressing aftermath of the earthquake, when an outbreak of cholera broke in Haiti’s Center and Artibonite departments. As of last year, six years since its outbreak, approximately 40,000 people have fallen ill. In September, I visited a cholera treatment center in Belladeres, a border town in Haiti’s Central-east which was home to many cases. During this trip and our visits, I was reminded how much of a burden such outbreaks are on an already weak healthcare system. The impact is heavier in isolated towns and villages, where resources are often scarce. The route, from the epidemic’s very start to the current phase where the incidence is the lowest since 2014, has been paved with lessons that could benefit the entire system.

Improving leadership and management. As a medical student back in 2012, I found myself hanging onto every word of Dr. Junot Felix addressing an inquisitive audience during a conference. As a senior public health professional, he stated that “the biggest obstacle facing Haiti’s healthcare system is a lack of competent managers”. As both management and leadership are vital to progress, his statement hinted that Haiti needs more people who are willing to highlight the best in each other and organize to provide the best possible care to the population.

Large and inclusive conversations need to happen between actors from public, private and NGO sectors- regardless of their many differences and priorities- to create liaisons, learn from each other about what has worked in the past, how to handle the current reality and bring forth solutions for the future. This is the type of collaboration that took place in elaborating and executing the plan to battle cholera.

Multi-sector workshop on cholera in Mirebalais, Haiti

Multi-sector workshop on water and sanitation and cholera in Mirebalais, Haiti

Gather and share timely information. When I started working as a practitioner, in a private clinic, I was forced to work while in the dark about crucial information. National health data was either unavailable to me or outdated. I could not accommodate my practice effectively to special trends, especially when it comes to transmissible diseases. This is also the case for State institutions and many NGOs, entities charged with gathering and sharing information at different stages of their programs to contribute to the management of prevalent health issues in Haiti.

Such weaknesses have also affected the war on cholera, where sharing timely information is oftentimes as crucial as setting an IV line. But thanks to the cooperation between the actors in charge of responding to the epidemic, the situation is slowly improving. Were it not for constant efforts to initiate and preserve this synergy, project management and delivery of care and services would be ineffective and resources, used inadequately.

Monitoring sheet, provided by the Haitian Health Ministry, to report new episodes of diseases in hospitals and health centers

Develop an entrepreneurial culture. I have been following Daniella Bien-Aime, a blogger who strongly advocates for an entrepreneurial culture to counterbalance the aid perspective in Haiti. In my opinion, this would also benefit the health sector which is almost entirely funded by international donors. Although international aid has been pivotal to improve health indicators in Haiti in recent past, it is not sustainable for an autonomous healthcare system. International aid leaves little to no place for innovation and competition, and kills local initiatives at an embryonic stage. This is in part why doctors, nurses, midwives, pharmacists and laboratory scientists seek NGOs jobs, abandoning State hospitals and local clinics, or simply leave the country.

Promoting local initiatives either in Port-au-Prince and outside is the first step in instilling this paradigm shift. Raising awareness is one thing but proper training and support programs intended for local healthcare professionals could also breathe new life into Haiti’s healthcare system.

Improve health literacy. Health literacy affects every element of the health care system. This observation brought my colleagues and I to create integrAction, a project dedicated to health literacy which led online campaigns during the Chikungunya and Zika epidemics in Haiti. Health literacy is the ability to obtain, understand and master the health information necessary to make advised decisions. The goal is to make the complicated health system easier to navigate, through health promotion, communication and literacy.

Such initiatives might be largely helpful to the future of Haiti as they help lower the burden of preventable diseases, deaths and consequently lower the amount of money spent on these issues.

The cholera epidemic remains an unprecedented challenge as we work towards its elimination. Almost seven years past its introduction in Haiti, Haitians can use their experiences to look at the future with tenacity and a clearer vision. “We are here, fighting…” a drinking water technician said as we left Belladeres. My short visit there did not allow me the opportunity to implement any lasting change. Neither will any quick fix resolve the problems that lead to the recurring public hospital strikes,  as they are a mere symptom of a deeper issue. As I lay down these recommendations of mine, to anybody reading this, I hope that the seeds will take root to bring forth a brighter future because of our common engagement.

This post, published in 2015, has been updated and edited to appear on Woy Magazine

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Uncategorized

Resilience is resistance

Being the first black republic in history on 1804, it goes without a doubt that Haiti was born in unbearable suffering. More than two centuries later, the country’s history still holds an uncountable number of tragedies and struggles, begun with the assassination of Jean Jacques Dessalines, the founder father of the nation. To make a long story short, political instability and corruption coupled with several natural disasters have plunged the western part of the Hispaniola island in deeply rooted poverty. But contrary to popular beliefs, such conditions of existence are far from abating the people. As an example, on his visit in 2010, former France president, Nicolas Sarkozy was right to affirm that though it was bruised on a never-ending night (January 12), Haiti has remained standing. A lesson of courage to the world.

Resilience, which has nothing to do with invulnerability and social success, is the key to unveil this mystery. The french psychiatrist Boris Cyrulnik defines it as the ability to stand against all odds and pursue one’s development despite the many adverse circumstances. Resilience relies on multiple factors to grow, among which four can easily be identified in Haiti: the creole language, religion, community life and music.

A language is a powerful tool that allows you to communicate your whole person besides expressing a practical idea. In the case of creole, it is strongly tied to the Haitian’s creative mind. Through its flexibility, It offers a wide opportunity to appropriate oneself of a situation and consequently hold power over it. The Haitian humor has been well expressed in the word “goudougoudou”, based on the sound of concrete-made houses shaking during the earthquake. The word aimed to name the event but also gave the people a certain level of familiarity with the disaster and the ability to raise themselves over it. Other creole words or proverbs are as powerful such as “wozo” (reed in english) meaning that Haitians may bend over but never will they break down. However, creole is not the only factor boosting the Haitian resilience.

From the beginning, religion has played an astonishing role in the slaves’ ability to cope with their situation and to overcome it with courage and pride. The story of Bois-Caïman ceremony which led to a catastrophic revolt, testifies the importance of religious gathering through Haitian history. It was such a known fact that the French have forbidden all kind of vodoo practices in Saint-Domingue colony. But as the iconic group Boukman Eksperyans asked in “Kouman sa ta ye” song: “what would it be like, if it wasn’t for vodoo?” Until today, the majority of Haitians practice vodoo (though secretly because of cultural discrimination) along with Catholicism and Protestantism which are highly spread and constitute deep sources of hope and force for the people. No matter the confession, religion remains an unquestionable pillar for resilience building in Haiti.

Cayman wood ceremony by Ulrick Jean-Pierre

Cayman wood ceremony by Ulrick Jean-Pierre

In line with religion, community life is another big rock in the process. It is common in Haiti to assimilate neighbors to family. Activities like agriculture, religious practices, commerce and entertainment evolve around various size of more or less constant communities. Even impermanent ones play a major role, like a cheerful tap-tap or a marketplace where strangers share a portion of their life with anyone like old acquaintances . In Haiti, the communities constitute an appropriate frame necessary to nurture one’s character and contribute to his continuing development no matter life’s circumstances. In hard times, when a hurricane hits or during the post-earthquake period, when a mother, a father or a child dies, when losses are unexpected and hard to accept, having a community to rely on is already a step towards a new beginning. In brighter moments like a child-birth, a kid’s first communion or a large harvest, the community’s presence remains highly reliable.

The last growth factor for resilience we’d like to describe here is not however, the least prevalent nor important. Every second of an Haitian’s life is punctuated by music. It lives in his soul no matter the type, the more popular being konpa, rasin and creole rap. The current president himself, is a former popular singer and musician of the konpa group Sweet Micky. Music is the perfect vehicle for expressing the dreams, fear, sorrow, beauty, sarcasm, accomplishment, spirituality, political position or any common life experience. It is where Haitians look at life, grasp it, question it and make it their own. Every moment of life- carnival, protests or elections- carries a variety of rythm or definite songs. With the power of music, the most unbearable situations become poetry, a comfortable place to grow better and be more resilient. As an example, Zenglen reminds people to keep fighting despite the daily struggles in its song “Rezilta” (Results). More others can be found to illustrate the importance of music in growing resilience. This is absolutely why carnival and rara can be counted as the most popular seasons in Haiti.

This analysis of the four different elements cited above, under the light of Haitian history and daily life events, has let us trace down their impact on character building, on the way they help people turn tragic events into relatively harmless memories and definitely how they contribute to development of constant resilience in Haiti since centuries. This core attitude is critical to the existence of Haitians as a people. Resilience is their resistance. Resistance against inertia, defeat, resignation and mind slavery. As the Haitian proverb goes: “Toutan tèt pa koupe, li espere mete chapo” (As long as the head is not cut off, there’s hope to wear hats). Day by day and one stone at a time, Haiti will strive to keep building its resilience castle.

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HIV/AIDS, Public Health

HIV/AIDS and Discrimination: A wrestling history

wrestling

As I was completing a two month internship in Brussels, I surprisingly noticed that my coworkers knew little to none about Haiti and its troublesome yet tremendous history. Their rare assertions turned around the political instability and discriminating facts pertaining to the HIV/AIDS epidemic evolving in the country since at least three decades. As a matter of fact, the HIV virus (isolated by Robert Gallo and Luc Montagnier in 1983) has originated in West Africa and spread to humans since the early 20th century. Since the very first years of this 30 years-old pandemic, discriminating ideas have travelled the world and survived until today, even among the most academically educated people. Looking at the history of the deadly disease, I’ve come to realize how the fight against social and ethnic discrimination has led to outstanding progress towards a better future.

The year 1981 marked an astonishing turning point in human history. On June 5 of that year, the Centers for Disease Control and prevention (CDC) published a report of five cases of a rare lung infection known as Pneumocystis carini pneumonia (PCP) among gay men in Los Angeles, USA. In New York and California, cases of a rare cancer, Kaposi’s sarcoma, were also reported to the CDC in the same period, leading to a total of 270 cases in the USA, by the end of the year. The general press prompltly used the terms “gay related immune deficiency” and “gay cancer” to describe the new disease and suggest a link between homosexuality and the disease.

On 1982, among the cases reported to the CDC, 34 were Haitians residing in the USA and eleven in Haiti. This discovery has led the CDC to conclude that being Haitian was a separate risk-factor for the newly spread disease and coined the term “4H disease” to point out male homosexual, heroin users, hemophiliacs and Haitians as at-risk groups. With such a denomination, it was the beginning of an unprecedented discrimination era based on sexual orientation and ethnicity. In a study published in 2010, it is stated that the HIV discrimination against Haitians resulted in the devastation of Haiti’s fragile economy.

The discrimination had serious consequences in regards to the spread of the disease. People with symptoms suggestive of the newly identified syndrome lived by fear of rejection, quarantine or violence. Until today, discrimination remains a challenge when it comes to treating the disease. It is a common factor contributing to delayed treatment in HIV cases, even in developed countries. It also impairs the public health strategies dedicated to test at-risk populations and control the epidemic. Therefore, the fight against AIDS has always been tightly linked to the fight of discrimination. At the time of “4H disease” there was a social, cultural and scientific (because of a poor understanding of the new syndrome) barrier which threatened the proper management of the epidemic.

100.000 Haitians protested in NY against FDA policy on blood donation Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

100.000 Haitians protested in NY against FDA policy on blood donation
Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

In this context, an unexpected event happened in the United States. On 1983, a New York doctor was threatened with eviction from his building for treating HIV patients. It led the Lambda legal group and Gay Men’s Health Crisis to file and win the first AIDS discrimination lawsuit in the USA. And, in July, the U.S. Congress enacted the Americans with Disabilities Act (ADA) which prohibits discrimination against individuals with disabilities, including people living with HIV/AIDS. Even though discrimination against gay communities persists today, this was a shining light spread upon the entire world regarding the necessity of banning stigma.

Years later, in New York, home of the largest Haitian diaspora community, 100.000 Haitians assembled and marched on April 20, 1990 in protest against a decision of the CDC forbidding Haitians and sub-Saharan people to donate their blood to blood banks. As reported by the New York times, Dr. Jean Claude Compas, said, “This policy is on the basis that Haitian blood is dirty, that it is all infected with the HIV virus. The decision is based not on sexual preferences, but on nationality, ethnicity.” Placards mentioned: “We’re proud of our blood,” and, “Let’s fight AIDS, not nationality.” Following this protest, a Food and Drug Administration (FDA) advisory committee voted to urge the CDC to abandon their policy based on exclusion.

100.000 protesting in NY against FDA policy on blood donation Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

100.000 protesting in NY against FDA policy on blood donation
Photo credit: @carelpedre twitter account. April 20, 2015 @ 7:55 AM

There is no doubt that in every corner of the world, discrimination against HIV infected people of any social category and ethnicity has been fought with vigor. In the light of the essential principles which guide humanity, AIDS is regarded today as a chronic disease and infected people ought to be cared for with the utmost dignity. To repeat the words of Ambassador Deborah L. Birx, “We won’t see an end to the epidemic as long as people living with HIV/AIDS feel unsafe and are forced to the fringes of their communities” The two major events described in this article have helped the world acknowledge how critical the battle for human rights has been in insuring a better future for all. Haiti is experiencing a declining prevalence since 1990. In this era of globalization, it can only be great news for the world. But this success is fragile and our common effort is required to sustain it. Share this paper in order to raise awareness on the need for inclusion and respect of all human rights no matter their health status.

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Public Health

WHY YOUNG DOCTORS LEAVE HAITI

This article was originally posted on Woy Magazine

Despite the many efforts of the health ministry and its partners, the Haitian sanitary landscape is plagued by chronic and infectious diseases and trauma. Half of the country’s population suffers from hypertension (EMMUS V) , and four years ago, a major cholera outbreak erupted killing thousands of people. Unfortunately, the level of sanitary education in the Haitian population remains among the lowest. These factors, coupled with some of the worst conditions in the northern hemisphere contribute to the 61-64 year life expectancy (EMMUS V). In the midst of this catastrophic public health state, a staggering number of physicians leave Haiti year after year, further exacerbating the 2 doctors for 10,000 inhabitants ratio. Why is Haiti’s health sector experiencing such an exodus? This article’s aim is not to exhaustively analyze all of the reasons why Haitian physicians leave, but to discuss the reasons I  have observed among my peers.

Poor financial reward

A licensed doctor- either a general practitioner or a specialist- employed by a state health care institution, earns around 32,000 HT gourdes a month. This is the equivalent of US $7,384.61 a year, according to the national bank exchange rate. While some doctors run private clinics, it is not uncommon for many to work for more than one institution in order to earn a decent living. In this field, as in any other in Haiti, it is difficult to secure a good job, and clinics bring less and less income because people lack the means to pay private doctors. It should be noted though, that some doctors who own private practices are very successful.

Let us dare a comparison: In France, the average net salary of a general doctor is € 6, 664 a month (UNASA, 2012); which is the equivalent of US $103,958.4 a year (€ 1 = US $ 1.3 in april 2012). As Atul Gawande stated in his book Better: A surgeon’s notes on performance, in 2003, the median income for primary care physicians in the USA was $ 156,902, and for general surgeons, it was $ 264,375. Active orthopedic surgeons, cardiologists, pain specialists, oncologists, neurologists, hand surgeons and radiologists frequently earn more than half a million dollars a year.

Inappropriate work environment

In addition to the poor financial reward of practicing medicine in Haiti, the work environment is not ideal. When it comes to the health care system, one can easily notice a significant difference between reality and what is reported. Poor governance by the ministry of health has led to a residency fiasco, where a group of state students have used intimidation and false propaganda to make the ministry withdraw previously held fair policies. The programs themselves are poorly run in terms of leadership and mentoring. A lack of proper andragogy plagues the tutoring program, and fear and brutality are frequently used teaching methods. Therefore, the results are far from what is expected; the physician, who is supposed to be the kindest human being, tends to lose his/her humanity in such a situation. This sense of humanity is also slapped on a daily basis by the uncleanliness and the unpleasant odor of the work place

The health care system is broken in so many ways, it seems like we do not have the necessary administrators to fix it. The eternal war between public and private medical schools can prove this fact. As a result of the weaknesses of the system, the hospitals lack even the basic materials like sheets for the beds, gloves for doctors and nurses and sterilized equipment. Often, the materials available are so outdated; they can not be properly used to save a life in a matter of minutes.

Examination room of a community health center at Jalouzi, Port-au-prince

Examination room of a community health center at Jalouzi, Port-au-prince

Lack of continuing education opportunities

For the doctor, education does not stop the last day of medical school or residency program. Practicing medicine is a lifetime commitment to study and research. It would be unfair not to acknowledge the efforts of the health ministry to provide Continuing Medical Education in Haiti. But again we are faced with the inequity issue, as these opportunities are not available for every doctor. In fact, not enough resources, mainly live events, are available for the number of physicians requiring such initiatives in Haiti. In the USA, the American Medical Association has gathered resources to help physicians meet their professional goals. These resources include things such as: live events, written publications, online programs, audio, video, or other electronic media.

Lack of Confidence

Haitian doctors are aware of the worldwide situation of the medical science. Thanks to globalization, foreign doctors can personally engage with doctors in Haiti and vice-versa, to learn from each other and improve their skills and medicine in general. On such occasions, a feeling of low self-esteem seems to conquer too often the minds of even well trained Haitian doctors. As a consequence of the previous flaws described, there is a feeling of shame that adds to the burden. The lack of confidence makes many Haitian doctors doubt their skills. As one stated in a conversation: “… [I would] rather be a good nurse in the USA or Canada instead of being an unqualified doctor in Haiti.” While Haitian doctors have shown impressive skill and judgment no matter how poor the work setting, low self-esteem remains a poison.

How is it possible that our basic conditions are so unsatisfying? Over the years, I have realized that arrogance, greed and incompetence are given the priority over what truly matters. Politicians only care about their own agenda instead of the health of the people. Therefore, bad governance leads to such unresolved crises. The status quo is guarded by people who are in position of power as long as it is profitable for them. Exclusion is then the norm. We must tackle all of these issues to prevent this massive exodus of young Haitian doctors.

I personally work with people who dream to become cardiac surgeons, army surgeons, health system designers, health care entrepreneurs, world-class professors, genetic researchers and more. I work every day with people who are motivated to pursue and conquer their dreams. The ambition is palpable. But where in Haiti can a doctor receive such training? How can a Haitian doctor lead such a fruitful career without eventually leaving one day?

Let me be clear, I do not wish to judge the quality of medical training in Haiti. I do not have the competence required to do so. This is what I do know, doctors who refuse to settle for the Haitian system are searching for an inclusive system, better work environments, open opportunities to learn more and greater financial reward. Correct me If I’m wrong, in any well-functioning society, these factors are any professional’s most basic rights.

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