Have you ever gotten a chance to see how one of your ‘one in a million’ cases turned out? You know, the gunshot to the chest that got opened in the ED and actually lived? In emergency medicine, unless you work in an academic center doing research, most of our cases are lost to any long term follow up. But that doesn’t keep us from wondering just how things turned out. Did that kid go on to become a healthy athlete with a bright future or is he stuck on a ventilator in some rehab center, sucking up millions of dollars while he waits to die?
In my career, that one-in-a-million case was my experience in the post-earthquake relief effort in Haiti, two years ago last month. As you’ll recall, on January 12th, 2010, the initial earthquake that hit the island lasted for less than a minute, but ultimately resulted in the deaths of up to 300,000 people. The quake resulted in hundreds of thousands of tons of debris that in many cases had to be removed by hand, and which left over a million people homeless. While there were a number of non-governmental organizations (NGOs) working in Haiti before the quake, since that time the number has swollen to over a 1000. In the past two years hundreds of millions of dollars in aid has been pledged by private donors, the international community, and governments to help Haiti recover.
And so it was with great interest that I took the opportunity to lead a group of colleagues back to the island on the second anniversary of the quake. While our initial aim was to lead a group of physicians and concentrate our time on clinical issues, in the end the group was evenly split between emergency physicians and post graduate students studying disaster relief. The central issue that we asked the group to examine was this: How does disaster relief morph successfully into long term improvements in health care? Did our short term help improve health care in Haiti, or did we actually leave them worse off? Instead of sitting in a conference room listening to experts, our group travelled the streets of Port au Prince talking to locals and NGOs, visiting hospitals large and small, eventually talking to people at the highest levels at the UN and the World Bank.
Of course, no one seriously questions the value of the initial relief efforts. Thousands of lives were saved and incalculable suffering was attenuated. But as Haiti has drifted into a welfare state, many are starting to ask whether the long term detrimental effects of such benevolence outweigh the initial benefits. On a grand scale, Haiti has become a metaphor for evaluating the risks and benefits of health care the world over. Though in no way did our group attempt anything resembling an academic study of the problems of Haiti’s health care challenges, we were able to make some general observations that were eerily analogous to the problems that we face in our own United States.
Medical records at a small hospital in Leogane
The first problem that we noted was the difficult balance between the needs of the whole versus the individual. Faced with the suffering of an individual, particularly a child or someone desperately poor, it flies in the face of humanity not to do everything possible to make that person whole. But the fact remains: to do so takes precious resources from the larger population that could lift the healthcare of many. It wasn’t always a stark either/or question, but the issue was always hanging in the backs of every discussion of allocation of scarce resources. Even Dr. Paul Farmer, founder of Partners in Health, who has been credited with some of the most successful treatments of drug resistant TB in Haiti – and was chosen by former President Bill Clinton to be a special envoy to the Interim Haiti Reconstruction Fund – took criticism. After visiting a state-of-the-art hospital being built by PIH in a small town about an hour from Port au Prince our group went to the remote island of La Gonave. The administrator of the island’s only hospital pointed out that the PIH hospital, while being a 300 bed free hospital, was costing $17 million to build and $9 million per year to run. His 100 bed hospital served a similar sized catchment area, was struggling to survive and had only $500,000 with which to build. Operating funds were from charges to already impoverished patients and revenue from a guest house lodging volunteer doctors.“PIH has sucked the wind out of every other hospital in Haiti,” he said.
A view of the Ijans (emergency room) at Zanmi Lasante (the Creole sister organization of Partner’s in Health), Dr. Paul Farmer’s first hospital.
So which is better, we asked him? To build a great hospital that can train doctors for the future, while other clinics remained poorly stocked and run by nurses making $10/day. Or spread those resources to benefit the most now. He wouldn’t take a position, but it was clear that his major concern was the patients directly in front of him.
After visiting a clinic operating in Cité Soleil, one of the largest and most violent slums in the world, our group engaged in a spirited discussion of an issue that emergency physicians seem to confront every day – the rights of recipients of aid. Citing the long history of oppression of Haiti and its people by the western world, our students studying third-world development argued that it was simple social justice for outsiders to remit millions to Haiti without any strings attached. It was for the Haitians, and Haitians alone, to decide how donated funds should be allocated. To do less would disrespect Haitians and Haitian sovereignty. Others, mostly the emergency physicians, saw it as wasteful – perhaps even harmful – not to keep a tight control over how development proceeded. In the end, one high level development official summed up the conundrum. He called the government of Haiti a ‘cleptocracy’, and described how the President of Haiti had appointed a co-chair to former President Clinton’s fund for the express purpose of frustrating any progress. In the end he admitted that any and all development will fail if it does not have Haitian leadership.
It reminded me a little of the schizophrenic discussion that we have had on-going in our country about how best to provide health care services to the poor. Emergency physicians become cynical and discouraged by the daily flow of patients who exhibit an attitude of entitlement while refusing to take personal responsibility for their care. Is this simply a failure to get buy-in from those receiving the care?
As our conference progressed there seemed to be one overarching issue that impacted and sometimes defeated progress at every level: the interrelatedness of every problem and solution to another problem and solution. For example, HIV levels in Cité Soleil were through the roof, largely because of a social structure that allowed, or even encouraged, men to have sex with whomever they wished. Gang rapes were a way of life for many women. One suggestion was to provide condoms, another was to educate women as to their intrinsic value. Or give the women jobs that will allow them to move out of the slum. Or bring in more police to prevent rapes and provide women with a reporting mechanism. The police, we were told, were part of the problem and were not trusted by the people. Men must purchase condoms and won’t use them anyway for cultural reasons. The women were uneducated, dispirited, and consequently incapable of finding jobs that would allow them to move out of the slum. Whatever suggestion was made, it was easily checked with another problem.
Whether we realize it or not, most of us are reductionists. We like to think that if we can just find the root problem and fix that, everything will fall in line. But the truth is that most problems are multifactorial and have to be attacked on multiple levels simultaneously. It is not uncommon to solve one problem only to see another surface as a result. And that can result in an overall sense of failure.
Whether we were talking to a nurse in Leogane, the epicenter of the destruction, or a developer in Mirebalais, the home of PIH, they all seemed to fall into three ways of looking at the problems. There were the starry-eyed optimists who mainly focused on individuals. Like the man who had left Haiti as a child with his family, grew up in rural Ohio, eventually won a scholarship to Duke University and was now returning to Haiti. Such stories were inspiring, and gave rise to soaring rhetoric about Haiti’s past as the “Jewel of the Antilles”. But the rarity of such successes seemed to highlight the problems in the larger picture.
There were also plenty of pessimists – it was easy to see only the myriad of seemingly unsolvable problems. Health improvements were stalled because there was no permanent housing. There was no housing because there were no jobs. There was no jobs because there was no education. There was no education because there was no money. There was no money because donors didn’t trust the Haitians. And on and on. It was easy to find numerous examples of how every solution for every problem would be defeated by some intrinsic unsolvable problem. And while individuals displaying this attitude might see the benefit of what they themselves were doing, they saw only problems in those around them. Ultimately they had no hope of seeing real improvements in the larger picture.
And finally, there were the “tweakers.” What our group eventually settled into was the attitude of being fully aware of the myriad of problems, recognizing that large scale successes would be difficult, but also understanding that modest successes over a sustained period of time might eventually achieve the desired goals. We realized that we were only tweaking the system and the long cultural history of Haiti. Nevertheless, we could see through the eyes of hope how little changes could grow.
Everyone who went to Haiti came back changed. Some were discouraged at the lack of progress. While we had saved the victim from death, so to speak, he was a long way from recovery. But we all returned with a renewed appreciation for realities of recovery. As we all know, but don’t often get to see, when we send the patient home, that’s not the end of the story.
Dr. Mark Plaster is the founder and executive editor of Emergency Physicians Monthly