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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Public health concern

Is Port-au-Prince’s Environment Making Us Sick?

The original version of this article is published on Woy Magazine.

A few years ago, I picked the front seat of a tap-tap heading to Pétion-ville. As usual with these common public transportation vehicles, the old car hardly moved up the hill to my destination. A couple of minutes later, a truck with the sign “O-Lavi”, selling clean water across the city, drove past.  A thick line of dark smoke coming from its muffler spread in the air and through the tap-tap which had no windows. The passengers started coughing, including the driver who had to park the car for a while because the dark smoke prevented him from seeing the road ahead.

Since then, I’ve experienced such events more and more frequently, making me wonder if Port-au-Prince’s environment is becoming a source of diseases. In fact, 12.6 million deaths linked to the environment occur annually in the world.  Many of the causes are partly due to environmental hazards identified by the World Health Organization: air pollution, community noise and poor sanitation. In Port-au-Prince, exposure to such hazards is almost unescapable. So I decided to look into how environmental factors are potentially affecting the residents of Port-au-Prince.

Air pollution

Toxic gas emissions often pollute places where most people live, since they also attend their occupations there. These emissions usually come from vehicles engines or burnt domestic wastes. For example, when vendors setup their businesses along the streets, trucks or motorcycles regularly pass or stop nearby. When the engine is started, merchants and passersby often inhale expelled gaseous components. People who travel via public transportation also inhale these while  stuck in traffic, because tap-taps and other vehicles used for Haitian public transportation are usually semi-open.

According to a study published in 2016, children from lower socio-economic households have a higher risk of specific respiratory health problems due to traffic volume and air pollution exposure. Further research found that air pollution contributes to the development of asthma throughout childhood and adolescence. Even when no specific link between air pollution and respiratory infections has been established in Haiti as of this writing, the latter is one of the most common causes of death among children. Despite these heavy potential consequences, air pollution is never a lone factor.

Community noise

Often associated with heavy traffic, community noise increases with the fast urbanization of Port-au-Prince. Business development attracts more people to the city every year and results in more and more noisy traffic jams.  In many neighborhoods, street vendors using megaphones to attract clients, churches with loud sound system, or a motorcade with roaring sirens are common occurences. In fact, the typical street scene in Port-au-Prince produces a cacophony. But the absence of a proper legislation shows the little importance attached to community noise.

In such environment, the level of stress among most people can quickly rise; especially among the poorest who tend to live in cluttered neighbourhoods. A study conducted in Ghana in 2015 revealed that occupational noise might increase the level of a stress hormone and the heart rate consequently. In my opinion, similar results can be found in Port-au-Prince. Overtime, this lifestyle might lead to a heavy burden of cardio-vascular diseases.

Poor environmental sanitation

Besides air pollution and community noise, poor sanitation is another environmental factor impeding the health of the population in Port-au-Prince. The remoteness of certain neighborhoods usually leaves little access to the city’s trash collectors. The high price of private services is often a barrier for many. So, people frequently fill the nearest gully and even the main roads with domestic wastes. When they don’t burn it, the trash remains in the communities for days. So as one goes through the streets, it is not uncommon to notice plastic bottles, used tires, or a dead animal among the wastes. Sometimes, even human feces stain the sidewalks, possibly a consequence of 6.3% of households in the metropolitan area having no toilets. The rain might easily carry away the wastes, polluting clean water sources.

The lack of a proper waste management system has made Port-au-Prince more vulnerable to the rapid spread of the cholera epidemic since 2010. It also opens doors to other diarrheal diseases- less known- affecting most children and malaria which is endemic in Haiti. Furthermore, a Zika epidemic to which poor sanitation is a vehicle is currently unfolding in Haiti, affecting thousands of people so far. Most of the people affected live in Port-au-Prince.

If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

On my way back from Pétion-ville that day, the bus I rode in trudged on despite the apparent malfunctions of the engine. Along the road, people went about their daily activities with no worry about any threat. Usually, the three factors described in this article here combine to provoke the worst. But life goes on in Port-au-Prince inside the smog filled air and ambient noise, merchants lay their foods on the bare ground, among garbage and dust. This is the daily life of most of the population amidst a lack of medical services. Actually, considering the potential impacts of air pollution, community noise and poor sanitation, the environment of Port-au-Prince suggests that the population’s health is unlikely to improve in the next few years. In hopes to reverse this trend, the public health and prevention advocates must join hands with environmental activists to fight these threats. If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

Paradigm shift

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Public health concern, Social Issue

The weight of social approval

During a short break from seeing patients, I was sitting behind the desk, enjoying an appealing novel. In the heart of the neighborhood of Jalouzi, in Petion-ville, the atmosphere was rather comforting, punctuated with laughter of children and chants of street vendors wandering outside. Betty, the nurse in charge of patients’ vital signs laid on the wooden bench in the waiting room looking preoccupied. At some point, she got closer to me and shared her concern: Ever since she started working at the center, she had gained several pounds and feared to have crossed the line of obesity, making her susceptible to the health threats associated with it (mostly cardiovascular diseases).

Betty is a short and curvy, 24 years old woman. She confessed to never doing exercise. Even back when she was at school, the court was too small and physical education wasn’t part of the curriculum. She also grew up in a family where women proud themselves on their thickness. According to her family and peers, it is a mandatory asset to attract a mate.

Generally, clinicians use the Body Mass Index (BMI) to assess the adequacy of weight in patients. This index, designated as indicator of fatness, is a ratio of the weight (kilogram) in relation to the square of the height (meter) of the person. A BMI score equal or greater than 30 is required to classify a person as obese while between 25 and 29.9, he/she is said to be overweight. In 2008, the World Health Organization reported an increase in the number of overweight and obese people, especially in developing countries where 115 million people bear the burden of disease due to obesity. It is important to note because in developing countries, including Haiti, the many health problems co-exist with poverty and a blatant lack of basic education, strengthening the vicious circle. As a consequence, the impact of obesity goes beyond the individual and also affects the State in terms of cost of related diseases.

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Betty had a BMI at 34; far along in the side of obesity. When I asked about her diet, she told me that she often consumes fried and greasy meals many times a day. Her sedentary lifestyle along with the popular culture that particularly promotes female thickness is also a factor. Other obese patients have even confessed to having resorted to self-medication and other practices to gain weight and develop a body shape, given the social standards, that is valued by most people. Bearing in mind the concept of health as defined by the World Health Organization, self-acceptance undoubtedly has an important role to play in the overall well-being of a person. But self-acceptance is sometimes too tightly dependent on social norms. Therefore isn’t it important in specific cases to question these norms and ideas of beauty that lead to self-flagellation and degradation of the body in the long term?

For instance, let’s go back to the origins of the Body Mass Index used to determine obesity. It was first described in 1832 by a Belgian mathematician and statistician called Adolf Quetelet. After the Second World War, it became crucial to develop a reliable index of normal body weight as the relation between weight and illness and death represented such a shattering concern in the medical world. But the researchers only referred to Anglo-Saxon populations to gather the data. Hence, the ideal Body Mass Index is not quite representative of the every person since African populations among other ethnics had been ignored in the studies. Another bias is that fat is not the only component of body mass. Muscle mass makes it even harder to generalize the obesity measurement standard. As a matter of fact, studies have shown that blacks have lower body fat and higher lean muscle mass than whites, so the same BMI score may lead to less obesity-related diseases. It doesn’t mean that the index per se is useless in African populations but the situation opens doors to further research which may lead to ethnic adjustments. In that vein certain groups have begun to lower cut-off points for the BMI of Asians.

After our exchange, Betty promptly acknowledged the challenge to merge her idea of beauty with her desired state of health. While the prospect of developing a perfectly objective standard for determining obesity and its health risks is still blurry, we need to keep in mind that the perception of beauty itself remains subjective. The balance between what is culturally preferred and what is healthy is also delicate and difficult to reach. Undoubtedly there seems to be a shift of consciousness among young women in Haiti. Hopefully properly designed and culturally tailored health communication campaigns are going to meet them halfway.

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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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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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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.

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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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