Public health concern

How social factors affect life: a health history

The morning breeze filled the room, warmed up by the first rays of the sun. That day, Jacqueline was the patient who kept my attention the most with her story. She was shambling as she entered the room, tightly holding an iron cane. The purpose of her appointment at the clinic was a monthly follow-up examination for diabetes and high blood pressure. A sixty-four-year-old mother, Jacqueline is suffering from obesity. She spends her days selling retail fabrics on the bare ground at the “Marché du Port”, familiarly called Gerit in Haitian Creole. Most of the time, her business doesn’t do well and she has to count on her daughter’s generous help. During history taking, as I asked her when did she become aware of her cardiovascular diseases, she started telling me about her life. This is how I seized the power of the determinants of health, these social and economic factors that influence individual and group differences in health status.

As far as her memory goes, it started on a 1987 Sunday morning. This sad November 29, marked by ruthless massacre, was the first Election Day in Haiti after the Duvalier regime. Gendarmes crowded the streets. On her way through the “Ruelle Vaillant”, seeking comestibles to feed her family, Jacqueline brought herself to the bloodbath. To avoid the gunshots, she jumped in the nearest canal and broke her leg bone as she fell. The effects of her broken leg remain to this day prompting her handicap. But on another level, the aftermath of the tragedy was so strong that it triggered emotional disorders in Jacqueline. Shortly after the event, she was diagnosed with high blood pressure.

Jacqueline stared at the ceiling as the memories streamed in front of her eyes. As she counted, the Hyppolite market was her main station back in the 80s. In these times, merchants only had to contribute a small fee to occupy a decent place. Under the mayor’s term, a hygiene service regularly cleaned the place, thanks to the occupants’ contributions. But since 1990, she moved to the Gerit following the orders of a new administration. The aging woman experienced since then, the precarious sanitary conditions and successive arsons which stain the history of the Gerit. Nowadays still leading a hectic way of life, her stress levels have skyrocketed. As the years passed by, she hasn’t even noticed how hastily the country was regressing. When I told her that the general hospital didn’t admit women to give birth for a mere 5 gourdes anymore, she couldn’t help but laugh.

gerit

Desperate merchant after fire destroyed her belongings at Port Market in Port-au-Prince. Source: BBC Pictures

Then, came the January 12. When the earthquake ripped her four-piece house, Jacqueline was left with nothing but courage. She never saw a home in the shelter an NGO provided her, but she still lives in it. Some days, she manages to make it on a 10 gourdes budget, hoping her daughter collects a decent paycheck in the USA. Diabetes hit in late 2010. She confessed: “As age and disease pile up, I don’t plan to rebuild the house. Medications are way too expensive and health is to be guarded like a precious gift”. The day I examined her, she was struggling with a sore foot which is oftentimes an indicator of bad compliance to an appropriate lifestyle and medications in diabetes patients. Her story was written on her foot.

Why does it matter? She did not predict the earthquake nor did she expect the many adversities she went through. But they acted as social, economic and environmental factors which have an important impact on her life and health. Many times, a single factor cannot determine the health issues a person or a community strives with. They prevail as the results of a cascade of events and behaviors which are deeply rooted in history and the way the society is organized. In Haiti, political instabilities and natural disasters played a pivotal role in the onset and development of many health issues. More than two decades after the “Ruelle Vaillant” massacre, the months following the 2011 elections, the cholera epidemic peaked in Haiti. One of the many reasons is the fact that Port-au-Prince was home to many cases and as rioters barred the roads, patients couldn’t arrive at the Cholera Treatment Centers on time.

The story of Jacqueline is similar to Jean’s, a 24-year old patient at the clinic. During a conversation, he affirmed: “I can’t explain why cholera struck me because I thought I was safe.” As scientific data show, the source of the epidemic lies in the unsafe disposal of Nepalese soldiers’ waste. Considering the persistent lack of sanitary infrastructures and the weak health care system, Haitians are more vulnerable than ever. This is factual because the social and political choices and events bear major impact on the population’s health.

For  a prosperous future, a stable society and the improvement of the living conditions represent the key stones. As a matter of fact, it is arduous to deal with bigger challenges like climate change, in a situation dominated by uncertainty, even though it also plays an important role in the health of tropical populations. By influencing the determinants of health, the next generation will be more likely to build a strong nation and plant a seed of reparation for Jacqueline and Jean.

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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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