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.

Click to like integrAction’s Facebook page

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.

SFPT2016

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

 

Standard
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.

Standard
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.

Standard