Haiti is always eye opening for me. From the magnificent clouds that caress the landscape, the overwhelming kindness of the people (many of whom outwardly have very little), to the prevalent horrors that afflict human beings – there are many “shocking” things here. As an outsider it is easy to be discouraged quickly by all that is apparently missing from the healthcare system, but one must not forget that Haitian nurses and doctors have been providing lifesaving care with any and all of the resources available to them.
Had it not been for the work of Partners in Health (PIH) during the last three decades, the number of preventable deaths in Haiti would have been innumerable. A month ago I was privileged to witness the magic of a magnificent new teaching hospital, Hôpital Universitaire de Mirebalais, built by PIH in the Central Plateau. It has abundant supplies, many providers, and excellent diagnostics including a CT scanner. In addition to providing high quality inpatient care in a resource limited setting (a feat that naysayers said was impossible) they are starting residency programs to train Haitian physicians who will ensure access to care for the most vulnerable of patients.
Of course not every hospital in a resource strained stetting can be Mirebalais. An hour away by road where I am working is the Haitian Ministry of Health (MSPP) district hospital in Hinche, and at first glance things stand in stark contrast. The internal medicine wards are three dreary rooms with a dozen beds each. There are no fans, no seats for visitors, and family members assume responsibility for feeding and bathing loved ones, as well as for cleaning the ward. I am discouraged to learn that there is a sporadic dearth of lab tests (we currently only have hemoglobin, hematocrit, CD4 counts, and urinalysis). On closer examination though, I see many marvels of modern medicine available to manage our patients; antibiotics, antiretrovirals for HIV, oxygen, xray and ultrasound. Our Haitian colleagues are used to practicing medicine with limitations– essentially relying on astute clinical skills and treating patient empirically when tests are not available. Now with the existence of Mirebalais the hope is that thoughtful transfers can be made when excellent care cannot be provided in Hinche. There may not always be lab tests to analyze the fluid, but we are able to drain swollen abdomens and lungs surrounded by fluid, and provide actual relief to suffering patients. Along the way our Haitian colleagues have taught us the art of healthcare without access to limitless diagnostics.
There is no denying that our sickest patients in Hinche would easily be in an Intensive Care Unit (ICU) in the United States. We care for a young man with AIDS and suspected PCP pneumonia who has an oxygen saturation around 75%, which hardly improves with the available oxygen via nasal cannula. While I stress over the lack of noninvasive ventilation (bi-level) or ability to intubate patients, my roommate who is a Haitian surgeon casually informs me that during operations under general anesthesia the nurse anesthetists must manually bag their patients. Our patient has slowly recovered as we treated him with an antibiotic and a steroid (bactrim and prednisone), and finally after three weeks of treatment he is almost ready for discharge. He will be plugged into the community health HIV services made possible by PIH in the Central Plateau. His survival in Hinche is a testament to the available and effective treatments in rural Haiti, but also proof of the creative solutions that our Haitian colleagues have been forced to employ as a result of constantly limited resources.
One morning as we begin rounds we learn that the hospital has run out of oxygen tanks. The charge nurse handles the situation and assures us that a new delivery will arrive in the morning (thankfully our patients remain stable until then). Every organization working in Haiti is similarly being challenged on a moment to moment basis; on another occasion we visit the Red Cross next door only to be informed that they have run out of blood. What I witness here reminds me that big interventions in global health are essential– research, antiretrovirals, large populations based efforts including vaccine drives and bed nets, but scant supplies also threaten patient safety. Although strides have been made in ensuring quality care, it is imperative that we keep advocating for the things we take for granted back home, things that may ultimately determine the difference between life and an anonymous death.
Varun Verma MD – UCSF Global Health Hospital Medicine Fellow