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
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

Standard
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

Standard
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

Standard