“Medicine is universal.”
This is a phrase that Dr. Pierre, one of my Haitian colleagues here in Hinche, uses frequently. What he means is that medical conditions and the treatments they require do not actually differ between a low resource setting like central Haiti and a hospital like University of California, San Francisco. Of course, some diagnoses here (malaria, leptospirosis, cholera) are rarely encountered on the wards of American hospitals. In addition, we must remember that illness is often shaped by political, social, and economic inequities. But the fundamentals of disease are the same; the human body doesn’t know that it was born across the border.
As an example, imagine a patient who presents with anemia. The differential diagnosis for this condition is broad, ranging from acute blood loss to infections like malaria to malnutrition to cancer. We have a variety of tests that can help us narrow the differential: we look at a blood smear, check a reticulocyte count and a mean corpuscular volume (MCV), order iron studies, maybe even proceed to a bone marrow biopsy. Each of these tests helps refine our impression and tailor our treatment. None of these tests are available here in Hinche. Instead, we play a game of probabilities, treating empirically for some likely causes and then following clinically. But in truth, medicine is universal—our patients in Haiti have the same broad differential for anemia, the potential to have any number of the long litany of diagnoses we see at our tertiary care centers in the United States. While practicality may dictate our diagnostic and treatment options, Dr. Pierre wants to remind us of the chasm between our reality and the ideal practice of medicine.
His point is an important one when we are faced with such significant limitations in the diagnosis and management of disease at St. Therese Hospital. It is easy to become accustomed to having little to work with, to forget the complexity behind the presenting problem because you lack the tools to parse it apart. But it is critical not to lose sight of our broad differential or the tests we would request, not only to keep the knowledge and practice fresh in our minds but also as a constant reminder of what we are striving towards for our patients.
And his point is particularly relevant when you are teaching the next generation of Haitian physicians. We are gearing up to welcome the Haitian social service residents, newly graduated from medical school and about to start one year of mandatory service, often in settings much like Hinche. As they begin working, the lack of resources may initially be a shock, but soon enough I fear they will become used to working with few diagnostic and therapeutic options.
It will take physicians like Dr. Pierre to mentor these residents and remind them of the depth and complexity of medicine. Through lectures, case discussions, and bedside teaching, we want to teach them some of those universal truths, to train their minds to think critically. At times, this may seem like an “academic exercise” when we lack many of the tools to practice evidence-based medicine here. However, we are working to support a new generation of physicians who know the theory, recognize the reality, and strive to bring the two closer together through clinical practice and broader advocacy.
~Robin Tittle, MD 2013 Global Health Fellow