Cholera, Global Health, Public Health, Public health concern

A Path to Fighting Cholera in Haiti After Hurricane Matthew

The rain was pouring as the car rolled towards Hinche. Kal and I were leading a team of doctors and researchers on a week-long investigation of factors related to the cholera epidemic in Haiti’s Center department a few weeks ago. As we went along the road, we could only look as far as five meters ahead due to heavy rainfall. I vaguely recalled hearing of a Hurricane Matthew forming in the Atlantic Ocean a few days before. The rain beating down on the area known as the “Bas Plateau” (Southern region of the Center) gave me a glimpse of the massive environmental and health consequences such a hurricane would bring to Haiti. My anxiety increased knowing that this specific department was the first, and one of the most severely, affected by the cholera epidemic ever since it was introduced in Haiti in 2010 due to improper waste management by UN peacekeepers.

Hurricane Matthew mostly devastated Haiti’s Deep South, affecting nearly 80% of homes in Jeremie, a coastal town in Grand Anse. Crops, livestock and drinking water systems also perished. As foreseen by health authorities and the population, outbreaks of cholera, which is endemic in Haiti seem to have quickly risen in several localities of the South peninsula. In light of my experience on the field in the Center, I propose a few strategic insights pertaining to cholera elimination in the aftermath of this disaster.

Decision making and public health interventions are more likely to be successful when they include members of the community served.

That is to say, the people from there who hold an attachment to that particular region, who maintain hope in the face of adversity and challenges as in post-Matthew Haiti. In my opinion, the water and sanitation technicians of the municipalities known as TEPACCs embody this idea. They are residents of the respective communities they serve. Oftentimes university students or local professionals, they are responsible for listing water sources and oversee the management of sanitation structures in the most remote areas of the country. The TEPACCs are widely responsible for the safety of the water consumed by most of the population and ensuring that waste is properly disposed.

These workers are familiar with all the localities and their physical and structural characteristics. During our time in Mirebalais, the TEPACCs Grandin and Cameau,  guided us to the remote areas, and informed us on the unspoken truths of these places where cholera has remained for 6 years. The cholera efforts and results all around the country would be far more effective if they were provided the necessary equipment they often lack such as, motorcycles so they can access remote areas easier, computers and cellphones to facilitate communication. In the aftermath of Hurricane Matthew because so many water sanitation structures have been destroyed, offering more resources to the TEPACCs is crucial.

The epidemic situation in the Center also reveals the vulnerability of specific regions where cholera persists in Haiti. Floods may have worsened the contamination of water sources in the South, as shown by more than four hundred suspected cholera cases, unconfirmed as of this writing. However, the focus should not be taken off previously identified zones of cholera persistence such as specific towns or regions in the North, Center, Artibonite and West even when they were not the strongly affected by Hurricane Matthew. Studies show that these zones of persistence play an important role in re-emergence of cholera during the rainy season because the transmission lingers even during the dry season. The increased cases during the rainy season such as the situation in Randel (South) right now- where an outbreak erupted even before the hurricane- is nothing but a mere consequence of cholera enduring in Haiti for 6 years. So, in addition to the added risk that Hurricane Matthew brought, these preexisting persistence zones remain the pressure points on which our attention should remain if we hope to eliminate Cholera on the island.

The reconstruction of water systems and protection of sources should indeed take into account these towns whose vulnerability have not decreased after Matthew. In Mirebalais, I visited a Cholera Treatment Centre (CTC) where there were more than a hundred cases in the last three days at the time of my visit. An officer of an international organization working with outbreak response teams on the field reminded me that the epidemic had been raging long before the hurricane. It is imperative that we do not forget that.

 

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La Theme River. Photo credit: Karolina Griffiths

In such a context, I do not share the opinions of some of my colleagues who dismiss the importance of vaccination, thinking it would be a waste of time, money and energy. As a matter of fact, the World Health Organization pledged one million vaccine doses to Haiti that 500,000 people could benefit from. Vaccinations may not the cure to the epidemic, but they can help save precious time and resources while we focus on strengthening our response capacity to outbreaks, improving access to safe water and sanitation, and educating at-risk populations especially in a post-disaster context. Education is crucial for behavior change, because many still believe that “cholera is spread through the air.” One man told us these words right before he nonchalantly dove in the Artibonite River that visibly contains dirt and sewage from the marketplace, the slaughterhouse and the prison.

The effects of Hurricane Matthew will be long term. The challenges of eliminating cholera by 2022 are uncountable. Based on my experience in research on the determinants of the cholera epidemic in the Center department alone, I foresee the benefits of strengthening the TEPACCs in their role, keeping epidemiologic surveillance in known areas of cholera persistence in Haiti and seizing this opportunity to vaccinate at-risk populations to prevent new cholera infections. This will be a heavy task, but this is a time where we, as a people, cannot afford to sink into fatalism or complacency. Hurricane Matthew is surely a step back, but it is also an opportunity to push Haiti forward towards progress and sustainability.

Read the original version on Woy Magazine

 

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Contact, Public Health, Social Issue

Why Haitian Doctors Choose To Practice In Haiti

Three months ago, I was granted the opportunity to present the results of an epidemiologic research (scroll down to CO-057) I conducted at the latest conference of the French Society of Pharmacology and Therapeutics; a scientific institute aiming to advance research on drugs and their utilization. Being a local-trained and based doctor in Haiti, I was twice as happy realizing the many promises of medical research for the country. However at the same time, the back of my mind was still being gnawed by the many obstacles afflicting the Haitian health care system. For example, while the epidemiological threats are quickly diversifying, basic data collection and analysis are still lacking. And a flagrant misuse of local capacities is in many aspects a scourge. As the ongoing strike of residents exposes the system’s shortcomings, it is obvious that such structural inadequacies have long resulted in junior doctors’ exodus.

Read “Why young doctors leave Haiti”

But against these odds, many Haitian doctors choose to practice in Haiti, despite increasing promises of improved work environment and better opportunities for doctors in foreign countries. Even among the large community of Haitian doctors practicing abroad, the desire to come back to the motherland is often expressed.

There is no one reason for that desire to stay or come back to Haiti. A colleague told me that Haiti is the only place he feels he belongs and connected to. That regardless of the state of the healthcare sector, he is more likely to stay in Haiti, strong of his familiarization to the Haitian culture and way of life. Some doctors don’t have a choice at all, staying because of family situations such as marriage or a chronically sick child.

As a reason for their coming back to practice in Haiti, a few of my former professors evoked experiences of exclusion, discrimination and racism which have contributed to drive them back where they feel more appreciated and needed. One day, as I was in Brussels for a medical internship, as I handed my passport to an office staff member, I was startled as he shouted to me how chaotic of a country Haiti is. That experience helped me catch a glimpse of what many might be enduring abroad in regards to discrimination pertaining to their origin.

Deep inside, I know that personal reasons such as lifestyle, family situations or unfortunate experiences abroad are not sole factors to embrace Haitian medical practice. As a matter of fact, while most doctors who leave always give me clear reasons why they do, most doctors who stay never seem to be able to give me a concise reason why they do. What is for sure is that whatever the reasons given, they are almost always associated with a profound feeling of patriotism and a sense of duty when it comes to practicing medicine in Haiti.

In fact, as I described in many of my articles, factors such as a lack of capacity and initiative hold back the Haitian healthcare system. But regarding its current state, one of my mentors affirmed that Haitian doctors, as every citizen, need to redefine their relationship to Haiti instead of abandon it. According to him, overcoming our shortcomings in regards to health care is a patriotic duty. But how many doctors are there, visionary enough to make it their mission to stay or come back here and try to improve what can be? I am honored to know and work with many of them. As I was recently discussing with two senior doctors, they consented that leaving might earn them less stress but also less happiness. Their choice was motivated years ago, ever since their career started back in the 1980s, by the ambitious project to train generations of doctors in Haiti to solve Haiti’s health issues. Let me clarify that leading a health-related project in Haiti is barely an easy task. I know that because the organization I co-founded, integrAction, has long been trying to find a working strategy to accomplish its mission which is to improve health literacy in Haiti. But with the experience I gathered, I realized that an often silent sense of patriotism plays a key role in keeping people pursuing their project. For me, there is no doubt that this is the most important reason why doctors still choose to practice in Haiti over many other choices. It is a crucial driver and that’s good because the fact is that Haitian doctors are critically needed on their land.

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This leads to another reason to practice in Haiti: the desire to cast a stone. Even though it’s a plausible argument for countless people, I’m not referring here to the year of service provided in exchange for the State’s investment in training doctors. In a broad sense, Haiti has nourished the personality and imagination of everyone who has spent time here. It has shaped who the people are- doctors included- through a complex net of trial and error, frustration and victories. And as the saying goes, much is often required from whom much is given. For a lot of Haitian doctors, staying in Haiti helps them to be useful and contribute where they are needed. And they all agree that politicians and those in charge of the health sector have the obligation to foster an adequate and coordinated work environment for more and better impact.

In the midst of a health system in crisis with no apparent short term resolve, my questioning the motives behind Haitian doctors’ choice to keep a practice in Haiti was both justified and eye-opening. It helped me determine where to look at in order to inspire the future doctors of this country. A mixture of personal preferences seem to be an important factor but patriotism and the aspiration to contribute to the community are also deeply ingrained. As Haitian doctors continue to build and struggle against all odds, the need for advocacy for an improved work environment and opportunities to live a fulfilling life in Haiti is mandatory. Human resources are the most important asset of any system and to achieve ambitious health goals, we need to maintain our precious medical work force.

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Presenting my research entitled “Evaluation of antibiotics self-medication among outpatients of the State University Hospital of Port-au-Prince, Haiti” on April 2016.

 

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Global Health, Public Health, Public health concern

Health communication in the time of Zika in Haiti

The day was coming to its end as I was dealing with annoying paperwork at an outpatient clinic in the area of Delmas, in Port-au-Prince. The attending nurse sharply knocked at the door and introduced me to Zoune, a woman in her mid-forties. Calmed by the fan in motion, the ambient heat hardly bothered on this particular afternoon. Even though January hasn’t seen any rain yet, puddles and piles of rubbish in the streets form a sure cottage for mosquitoes. The tropical temperature also stimulates their reproduction. Zoune presented clinical features of the Zika disease, urging me to initiate a symptomatic treatment based on my judgment and order a few screening tests. Ever since the confirmation of Zika cases in Haiti by the Health Department (and even before) the public carefully monitor themselves for signs of the disease and inquire with their doctor. Of course some prefer to get themselves treated with simple non-pharmaceutical interventions.

The Zika virus disease is transmitted by the bite of Aedes mosquitoes, infected by the virus. Identified in humans for the first time in 1952 in Uganda and Tanzania (Emerging point of Chikungunya virus which caused an outbreak in Haiti in 2014), it spreads especially in Africa and tropical countries. This non-fatal disease involves a febrile syndrome associated with lumbago (pain in the lower back), simulating Chikungunya or malaria which is endemic in Haiti. The emergence of Zika virus disease was foretold long before its introduction in Haiti. Climatic conditions punctuated by global warming as well as migration have positively contributed to its emergence.

Currently, one can refer to an epidemic in Haiti since Zika was simply non-existent across the territory. Even though it’s relatively simple to limit its spread- provided that hygiene and sanitation measures are met- difficulties particularly arise on this level. How to involve most of the people in this dynamic? Proactive communication is the first step in management of an epidemic. But between the limited resources and the outright flaws in the Haitian healthcare system, the public is far from being reassured. Communication weaknesses have already started to plague the good management of this outbreak, hence affecting trust even more. As a matter of fact, the confirmation notice of the presence of the disease in Haiti came late compared to expectations of the people who observed that it was rapidly gaining ground and awaited a word from the Ministry of Health.

According to my observations, the greatest fear of the public lies in the eventual complications of the Zika virus disease; mainly brain malformation in newborns and Guillain Barre Syndrome which causes paralysis of the body. Although scientific literature hasn’t confirmed any link between these complications and Zika yet, in some countries where Zika spreads, women are warned to delay pregnancy or to avoid areas affected by outbreaks. In the United States, the Centers for Disease Control and Prevention have elaborated guidelines for the screening of pregnant women by gynecologists. Some see this as a unique opportunity to revive the debate on abortion in countries where a modern law is lacking. But at the time of writing, no campaign whatsoever is officially launched in Haiti thus, no warning regarding pregnancy or increased promotion of contraception services has been issued by the Health Department. The public is therefore facing the fear of this epidemic with the feeling of being on their own.

In order to foster behavioral changes necessary to protect lives, it’s important to know the perceptions and existing practices of the population. A never-ending conversation with the public allows effective management and is worth more than sparse and scant monologues in times of panic. During the Chikungunya outbreak in 2014, the organization I co-founded integrAction was delighted to share ideas and experiences with the socio-medical staff of the Haitian Red-Cross (many of whom were infected) in Cap-Haitian during a conference. This initiative helped the organization conceive groundbreaking campaign with appropriate health communication to raise awareness via social media on the disease and the means to cope with it.

On a broader scale, the current turn of public health history is an opportunity to consider reinforcing leadership capacities from the bottom to the top, while investing in research and improving the public’s health literacy. For most of the population, there’s more fear than harm as in the case of Zoune. So engaging the people through proactive communication followed by prompt action is one of the best ways to halt the spread of Zika and its potential consequences. As they express much disappointment, the Haitian people can only hope for less vulnerability. But if today’s duties are unceasingly postponed, the future, undoubtedly, can only be more grim.

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador January 21, 2016. REUTERS/Jose Cabezas

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Public Health

How January 12 reopened the conversation on Haiti’s healthcare system

A typical January morning in Haiti, the 12th of the year 2010 greeted a bright sun and the usual bustle of the island life. While the majority of schools and churches were functioning as usual, traders crowded the pavements, carelessly dealing with their routine. Hope warmed up the hearts of the Port-au-Prince population, following the sweet Christmas of 2009 whose memories were still fresh. But on this day, a magnitude 7 earthquake was registered as a painful page in the life of the people, definitely changing the course of history by taking the lives of hundreds of thousands of Haitians. Countless people have suffered serious injuries, including those who have seen their mobility limited overnight or the ones amputated one or more members in order to survive. In all minds, fissures are still present today either as post-traumatic shock disorder or severe depression. Since then, new sets of questions have punctuated our daily lives, especially related to our way of embracing the future. This catastrophic event opened the way for new conversations about the Haitian health system. Words and ideas are far from exhaustion as the wounds are still slow to heal.

In March 2011, one year after the unfortunate event, Dr Jean Hugues Henrys, current Dean of the Faculty of Medicine of the University Notre Dame of Haiti, gave a speech at the Bloomberg School of Public Health. Through the course of his lecture, he has drawn the profile of the existing Haitian health system before the earthquake, compared to a set of decentralized health microsystem, in transition between infectious and chronic diseases. In the aftermath of the disaster, it was imperative to adapt according to Dr Henrys, because the many amputees were considered a priority, while hardly enough resources were available to support them. He also emphasized the urgent need to provide mental health services to the people while the subject was sparsely considered in the past, forsaking many to discrimination and stigma. This has revealed the lack of disaster preparedness that existed in the healthcare system on many levels: logistics, human resources and education.

For Dr Henrys, a partnership between public and private institutions would contribute to ensure a better future. Inaugurated two years after the earthquake, the university hospital of Mirebalais born of the partnership between the Ministry of Health and Partners In Health (US-based NGO operating in Haiti), treats patients through its various services and largely contributes to educate the new generations of nurses and Haitian doctors. It is among other projects that have emerged in an effort to better equip the country with capabilities to respond to eventual catastrophes seen as a constant risk.

But the lack of preparedness which patients were the victim following the January 12 concerned not only the psychological and medical care themselves but went well beyond. The Haitian health system was evolving in a chaotic situation and also deserved attention. The fear of a “phantom epidemic” of diphtheria fueled the minds for weeks following the disaster while a true epidemic was unlikely and coordination between NGOs was poor. In an article published in 2013 entitled “The celebrity as Hero: When Sean Penn has Fought Phantom Epidemic“, the American journalist Jonathan Katz counted the panic caused by the death of Oriel, aged 15 years, blaming the lack of a competent system which the teen’s parents could have used days earlier. The infrastructures already shaky before the earthquake, had completely disappeared on January 12, leaving the country in the most complete desolation when a cholera epidemic erupted by the end of the year 2010. More than infrastructural and organizational issues have been raised in the debate around the Haitian healthcare system after the earthquake.

Talea Miller quoted in her article “Haiti’s Health Care System Faces a Defining Moment” published in June 2010; Minister Alex Larsen said that the state of New York has more Haitian doctors than Haiti itself. While the exodus of health workers already afflicted the health system before the earthquake, it worsened after January 12 following numerous personal losses and the deaths of many doctors and nurses whose proportion in number was highest in Port -at-Prince. This chronic haemorrhage of medical staff also nourished the debate around the health system. With only 3.5 health professionals for 100,000 inhabitants, Haiti lies behind the standards stated by the World Health Organization. Paradoxically, the broken state of the Haitian healthcare system drives away its most important assets, while they are needed to fix it.

As reported by Talea Miller, Dr Larsen believed that human resources were more important than physical infrastructures in the wake of the earthquake and advocated the benefits of conjoined educational programs between Haitian and foreign universities. Since 2010, volunteer medical teams from the United States and Canada regularly participate in mission trips at the Hospital Bernard Mevs at Port-au-Prince and largely benefit the healthcare system in terms of services and education of emergency care physicians and pediatricians.

Six years after the earthquake, the Ministry of Public Health still faces much trouble in order to pursue its core mission. One of the major difficulties lies in the financing of the system. Despite their meager resources, the households finance 96% of their health needs in spite of the minimum package of services offered by the state. We must recall that the budget allocated to the health sector does not exceed 6% of the national budget. Regardless, new structures and programs are emerging across the country, primarily financed by donor countries. But in spite of this, health indicators remain alarming and the system statistically inefficient. At a conference on health financing in 2014, Dr. Jean Alfred Patrick mentioned that there is a weakness in the regulation and coordination of health financing systems in Haiti. In other words, bad governance plagues any sustainable progress in the health sector. Instead of motivating more Haitian doctors, this context contributes to push them towards immigration.

Today, January 12, 2016, as the Haitian people commemorate the lives of the earthquake victims, they consider the path already travelled and the long road ahead. Over the past 6 years, they have discussed on many platforms the best ways to redirect the public health priorities and goals, increase capabilities in disaster preparedness, enhance the mental health of citizens, reconstruct the many destroyed health facilities, retain qualified health professionals and promote good governance in the healthcare system. From the debates, tangible solutions have been considered and implemented. And as long as the conversations keep going, there’s hope that Haitian lives will stand on unshakable ground.

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Public Health, Public health concern, Social Issue

Let’s change the rules to save women’s lives in Haiti

Fairly called Poto Mitan in Haitian Creole, women account for 50.49% of the Haitian population and represent the center pillar of most households. From commerce to education, their contributions to the society are undeniable. As the prosperity of the nation relies on its citizen’s well-being, it is no surprise that women’s health is a public health priority when it comes to the national health policies. But despite the efforts, unsafe abortion remains unfortunately a scourge as prevalent as poorly addressed.

I recall my last shift at Chancerelles’ maternity ward where a 16 year-old pregnant girl presented with intense abdominal pain and massive vaginal bleeding. At first, she did not admit any medication ingestion prior to the onset of her symptoms. But as we pursue the medical investigations, her 30-year-old boyfriend confessed that he had provided her with 4 pills of an over-the-counter drug known to provoke abortion in pregnant women. For the gynecology residents, it was a routine and classic case. Yet openly discussing unsafe arrest of pregnancy in Haiti is controversial since it’s so much of a taboo.

The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both. Every year, 50.000 women, mostly from Latin America and Caribbean countries, die from consequences of unsafe abortion. According to the article 262 of the Haitian penal code, induced abortion no matter where or who performs it, is a criminal act and legally punished nationwide. But regardless of the law (or maybe because of it), complications of clandestine abortions are common motives of visit in general and obstetrical care facilities.

SDG3

Target: By 2030, ensure universal access to sexual and reproductive health-care services.

Carole, the latest patient I examined, was going through her second abortion experience and presented with severe anemia after 15 days of bleeding. When she got pregnant, economic difficulties arose, urging her to take the decision with her husband’s consent. But the specialized hospital she visited wouldn’t provide the desired services as forbidden by the law. So she turned to a clandestine clinic, even when the fees were high. As we shared our opinions, she said that it would be beneficial for women to abort safely with optimal medical assistance because the absence of a legal framework for safe abortion and technical capacities almost took her life away.

A few days later an obstetrician and HIV care specialist told me that to alter the perilous consequences of unsafe abortion in Haiti, it would be best to decriminalize it. Among the 530 women deaths per 100.000 inhabitants per year in Haiti, 120 are attributed to unsafe abortion. Fortunately, in the last quinquennium, the Ministry of Health has debated the subject and elaborated a new bill with several social groups to allow abortion for medical purpose and in rape cases. This is one step forward in the modernization of women’s health in Haiti even when it hasn’t reach the parliament yet.

But the main causes of induced abortion being socio-economic status, maybe the bill should also include women who desire to arrest their pregnancy for any reason other than congenital malformations or rape. It would be better if every woman could openly  discuss it with their doctors.

Because it is the State’s duty to guarantee optimal health care to the population, and health is not restricted to the body. It includes mental and social well being.

It would be valuable to couple activism with effective health communication. Because often, the barriers to improving women’s health in Haiti are some erroneous traditional beliefs. My intention here is not to downplay any religious or cultural values, as some have actually improved women’s health. My advocacy is to conduct proper scientific studies on this public health issue and clearly communicate the best ways to prevent the consequences. After all, prevention costs exponentially less than complication management and as the recently published statistics show, the State’s funds have long been depleted.

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HIV/AIDS, Public Health

A New Approach is Needed for HIV/AIDS Treatment in Haiti

Published in Woy magazine 

At 28 years old, Mariette is a young energetic woman caressing hopeful dreams for her child. She mourns the death of her husband, who recently passed away from AIDS (Acquired Immuno Deficiency Syndrome). Also infected by the HIV virus, she regularly receives a triple-drug therapy at the Justinien Hospital at Cap-Haitian. Regularly, Mariette and her daughter make the 45 minute trip from her hometown Limbé to Cap-Haitian to receive treatment. Like Mariette, many HIV-infected patients living in areas around Cap-Haitian travel to reach the Justinien Hospital for regular biological and clinical follow-ups.

Mariette is one of the lucky few able to benefit from antiretroviral treatments. While antiretroviral drugs have been available in industrialized countries since 1996, it was not until 2002 that Haiti received a substantial donation from the Global Fund to Fight AIDS, Tuberculosis and Malaria which led to the first treatment programs by two organizations fighting the disease on the field since its early days. In that same year, the World Health Organization released guidelines for the treatment of HIV/AIDS for the first time in history.

Despite such tremendous progress, not every infected patient could benefit from therapy immediately after diagnosis, mostly because of the high cost of treatment and the lack of health insurance. As noted by United Nations Program on HIV/AIDS, “by 1998, while 95 percent of people with HIV were living in poor countries, almost none had access to antiretroviral therapy, which then cost $12,000 to $16,000 a year per patient.” Among other reasons, it seems that this is how the World Health Organization determined patients’ treatment eligibility because it was simply too expensive to provide medication to everybody; so they prioritized the patients who were in more advanced stages of the disease, those who were much sicker. Therefore, it was not until Mariette became very sick that she was finally admitted to the hospital and was declared eligible for drug therapy in accordance to the 2010 guidelines, which are currently used in Haiti. This delay, from the diagnosis time to the start of her treatment, increased the risk of transmission in addition to other health consequences. Unfortunately, this is currently the story of millions of other HIV-infected people.

However, to decrease the spread of HIV/AIDS and ultimately eliminate it by 2020, scientists are planning a bolder strategy, named “test-and-treat”. The suggested strategy entails the initiation of therapy immediately after a positive HIV test, regardless of the biological and clinical parameters, as it used to be. Regarding this new approach, a recent publication on the medical journal The Lancet stated that: “Instead of dealing with the constant pressure of newly infected people, mortality could decrease… Transmission could be reduced to low levels and the epidemic could go into a steady decrease towards elimination.” As of this writing, test-and-treat represents the core strategy in WHO guidelines for HIV treatment, published in September 2015, 13 years after the original publication. If the Haitian government works to apply this as part of the national plan to eliminate HIV/AIDS in Haiti, more people like Mariette can start therapy sooner than she did and will have a higher chance of survival, without passing the virus to another generation.

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Today, Haiti is at a crucial point in the history of the 30 year-old pandemic, but faces many challenges to achieve the desired goal. In order to meet the gigantic promises of test-and-treat, the Haitian government must work towards a sound reinforcement of the healthcare system with a focus on the people by preventing the massive exodus of qualified health professionals. The fight against discrimination and stigma must become a priority, because every man’s life is valuable no matter his status in society. The number of testing centers in Haiti must increase for early detection.  The government needs to establish adequate cooperation with international partners in order to have available drugs for every infected patient. And most of all, we must continue to educate the youth about this virus. Marie-Ange, Mariette’s daughter is only twelve years old. However, Mariette ensures that she transmits her knowledge and experience fighting HIV to her young daughter. At the end of the day, as the sun began to retreat, Mariette boarded another tap-tap with her daughter to rejoin their community in Limbé. Because of the antiretroviral treatment, Mariette continues to hope.

 

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Global Health, Public Health

Insights from a surgical prowess

Founded in 1703, Mirebalais is a small commune situated in the Plateau Central, approximately 60 km Northeast of Port-au-Prince, the capital of Haiti. Birth place of the Haitian combatant Benoit Batraville, it is a 88.899 inhabitants, vivid locality where agriculture and livestock are predominant despite the many difficulties of commerce and daily life. Fortunately, the Peligre’s hydroelectric dam, opened 59 years ago in the Centre department, provides energy to the whole city. I first visited the town five years ago, immediately after the 2010 earthquake, with a team of medical students who volunteered at the hospital Bon Sauveur of Cange (village located near Mirebalais) run by the international NGO Partners in Health and local sister organization Zanmi Lasante.

In this 330 square kilometers town, five years later, a surgical team led by Dr Henri Ford, Haiti-born renowned surgeon, successfully separated six-month-old abdominal conjoined twin sisters. Being the first of its kind in the country, the successful operation marked a turning point in the history of Haitian medicine. This prowess, which took place at the recently erected University Hospital of Mirebalais, has drawn many insights on Haiti and the future of medical cooperation among which: the benefits of global health and surgery for the resource-limited country, the need for a paradigm shift in international medical cooperation and the opportunity to share an accurate image of Haiti.

Marian's surgical team wore red bandanas, while Michelle's wore yellow ones as they worked in an HUM operating room on Friday, May 22. Source: Partners in Health

Marian’s surgical team wore red bandanas, while Michelle’s wore yellow ones as they worked in an HUM operating room on Friday, May 22.
Source: Partners in Health

Let’s consider first, the benefits of global heath and surgery for Haiti. Defined as the area of study that places a priority on improving health and achieving equity in health for all people worldwide, global health stands as a common ground, where international and local health professionals perform together in order to overcome enormous challenges usually unconquerable by a sole performer. As noted, surgery can help reduce the burden of disease by 11-15% globally, but unfortunately, the poorest people have little access to surgical care for malformations and pregnancy-related conditions like it was the case for Ketan, mother of the conjoined twins Marian and Michelle Bernard.  In a context of economic insecurity and shortage of medical professionals, global health and global surgery, in Haiti, can be considered as one of the most accurate vehicule to strengthen the health care system by providing affordable access to care and sharing of knowledge and experience in the respective fields. The separation of the conjoined twins at the University Hospital of Mirebalais is a typical experience of the opportunities provided by surgery used in a context of global health.

These open doors consequently foster the need to look at the future through different lenses. They emphasize the vision that the new way of considering international medical cooperation should privilege sustainable partnership over mere assistance. This paradigm shift, in the case of Haiti, may come very gradually. Hence, the need of courageous visionary people here and abroad to challenge the status quo and be the change they want to see. The surgical prowess of Mirebalais is undoubtedly a milestone in the future of medicine in Haiti. It offers a fresh look on what is possible here where weaknesses are overly pictured. In the path of Dr Anténor Miot who introduced orthopedic surgery in Haiti, the vision and work of pioneers will definitely have an astonishing impact in the future. Not only will it lead to better care for the Haitian people but it will also propel a more accurate image of the country which is striving to build a resilient health care system.

In fact, as of the early years following the earthquake, Haitians recognized the need to share a new and appealing image of Haiti in the global scene. It comes in reaction to negative news, often spread by international medias through shocking headlines and repulsive photographs, emphasizing the state of poverty of the western part of the Hispaniola island. In the context of the separation of the siamese sisters, Haiti has retained a new kind of attention. There was extensive media coverage both prior and after the surgery by the Haitian newspaper Le Nouvelliste and international medias. The Huffington Post and CBS News among others have instantly released the positive news of the successful seven-hour surgery. As Dr Jon Lapook, CBS News chief medical correspondent, present at the event, stated “This is a country that’s trying to rebuild the health care system”. In fact, since positive changes are happening home, positive feedback will surely counteract destructive attempt.

Ultimately, leadership can be defined as the ability to inspire people to dream more, to accomplish more and to be more. It is a matter of influence through innovative ways to look at the world. No matter the field of action, no initiative will be sustainable without the necesssary amount of cooperation and knowledge sharing between people of different academic and cultural background. Therefore, the majestic surgery of Marian and Michelle Bernard at the University Hospital of Mirebalais has cast a bright light on Haiti’s future particularely in medicine despite the remaining challenges. It also outlined the power of taking impactful initiatives inside to bring a positive image outside of Haiti. In 2010, as I assisted my first surgery at Cange, I couldn’t imagine that such an astonishing event would take place at Mirebalais, little town where we used to stay not more than a few hours, the time to jump in a bus to Port-au-Prince. Next time you come across the astounding country of Haiti, make sure you pay a visit to the Hospital of Mirebalais which stands today as a cornerstone where history was written.

Manoucheca Ketan holds her conjoined twin daughters before their separation at University Hospital in Mirebalais, Haiti, on Friday, May 22. Source: Partners in health

Manoucheca Ketan holds her conjoined twin daughters before their separation at University Hospital in Mirebalais, Haiti, on Friday, May 22.
Source: Partners in Health

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