Two Worlds: Healthcare Disparities

Originally appeared in The Hospital Leader:
http://blogs.hospitalmedicine.org/Blog/two-worlds/Anyone who has worked in Haiti quickly realizes that injustice abounds. I had rushed into the cramped curtained off area and found the pregnant woman with her eyes rolled back to 2-o’clock. She was not responding. Even when I yelled to wake her or when I rubbed her chest forcefully with a clenched fist, she lay silently drenched in her sweat. Moments later though, she started shaking, and her head, chest and arms lifted up violently off the bed repeatedly as she seized. A nurse tried valiantly to re-check the blood pressure (the first reading had been 70/40). When I asked what had happened, one of two foreigners (apparently midwives) standing in the labor and delivery area shrugged and casually informed me that the patient had been seizing for an hour. An hour? I told the nurse to drop the BP cuff and draw up 1000 milligrams of phenobarbital (the only anti-epileptic available at our hospital).

Practicing medicine in rural Haiti is in stark contrast to the United States, where as a hospital medicine physician — I am privileged to be surrounded by specialists, have multidisciplinary help in every field imaginable from social work to physical therapy, and access to seemingly unlimited resources. My local colleagues in Haiti; whether physicians, nurses, pharmacists or administrative staff function in a system where an individual wears infinite hats, and recognition for their effort is often lacking. Contrary to ignorant beliefs, Haitian professionals have options too, since they could get better paying jobs in the capital or even overseas — apparently 80% of Haitian trained doctors do end up leaving the island. Local staff is no less zealous than outsiders about ensuring social justice in the resource limited settings in which they work (though they may lack the twitter or blog posts to advertise so).

As part of my global health hospital medicine fellowship at UCSF I have been working in a Haitian Ministry of Health (MSPP) hospital in Hinche, a town in the mountains three hours from Port-au-Prince. My primarily responsibilities include teaching the social service residents during rounds (medical students who have graduated but not completed a residency), sometimes consulting on cases throughout the hospital, and rarely direct patient care. The system does not reply on my presence, and unsurprisingly Haitian doctors manage just fine during the six-months of the year I work in San Francisco. In reality, I learn a tremendous amount from my Haitian counterparts — professionals who practice medicine with limitations unimaginable to those of us accustomed to 21st century marvels. When I first arrived, I was distressed to discover that diagnostic capabilities consisted only of malaria smears, rapid HIV testing, and hemoglobin/hematocrit. On top of this I ran into insufficient lab reagents, broken EKG leads, and no defibrillator. I was however grateful for the availability of xray and portable ultrasound. By the end of my first three months I realized that to Haitian providers, ensuring quality care is a day-to-day undertaking, and not necessarily an excise culminating in a neat poster presentation for a research symposium. Death on the wards is prevalent and lives lost are particularly heartbreaking because they are often due to lack of systems and supplies we take for granted in the U.S.

After the phenobarbital, the young woman stopped seizing temporarily, but fifteen minutes had gone by and we still had no oxygen. After I yelled at no one in particular (and then apologized), five Haitian nurses dutifully lifted the patient and carried her down the hall to where an oxygen tank had been setup. The Haitian obstetrician solemnly advised me to use any required medication since the fetus was dead. After discussing with a Haitian internal medicine colleague, I administered more phenobarbital, and added antibiotics and antimalarials — my best guess given her high fever and dangerously low blood pressure. I also gave her magnesium, because unlike in the U.S. where physicians strive for an eloquent unifying diagnosis, in rural Haiti we are forced to treat empirically. We had no ICU, no CT scan to examine her brain and no Neurologist. The patient’s family arrived and reported that the seizures had been present intermittently for three days until they got to the hospital. I had used nearly all the phenobarbital our pharmacy had, and despite this — with a tongue blade wrapped in gauze between her teeth, the young woman died less than twelve hours later.

Partners in Health, the Boston based not-for-profit has been fighting against “stupid deaths” for thirty years, with its mission to provide a ‘preferential option for the poor.’ Through a revolutionary system of health care accompaniment and relentless advocacy, PIH has ensured widespread access to antiretrovirals and TB treatments, as well as many important wrap around services such as nutritional support. More recently ramping up efforts on the inpatient side, PIH has built a magnificent 300-bed teaching hospital in another location in Haiti’s central plateau not too far from where I work in Hinche. University Hospital in Mirebalais boasts a CT scanner, operating rooms, specialists, and even an electronic medical record system. Besides the physical structure and resources — the PIH flagship will ensure that generations of Haitian physicians have another place to complete residency training in internal medicine, pediatrics and surgery. Many avenues of impact exist — but locals are the only ones that can be truly sustainable agents of change.

Despite tremendous progress in Haiti, it is important to remember that four years after an earthquake that killed hundreds of thousands, and left nearly a million people homeless — there is still much to be done. The block schedule some of us enjoy as hospital medicine physicians places us in a unique position to traverse two worlds and consistently be engaged in providing quality care in resource limited settings. Since evidence of adverse effects of outsider involvement is abundant in Haiti, perhaps the best approach is to emulate or join with PIH in working with the Ministry of Health, resisting the temptation of trying to establish a shadow or parallel health delivery model. Collaboration and not competition is needed going forward if we are to cause a convergence of the two realities of healthcare delivery in our modern world.