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Haiti: Six Months After, Part III

 Since last week, World Policy Journal has asked experts and aid workers in Haiti or recently returned their thoughts on the country's condition, six months after the earthquake. Today, we spoke to Christopher Dayton with the International Medical Corps and Partners in Health.

 
Christopher Dayton, MD, (see publications here) is a fellow at St. Luke’s Roosevelt Global Health Division. He has just returned from a 5 week trip to Haiti, his second after spending 2 weeks there just weeks after the earthquake. While in Port-au-Prince, Dr. Dayton worked in the General Hospital in Port-au-Prince, also known as HUEH (Hopital de l'Universite d'Etat d'Haiti) in the inpatient ward and in the Emergency Department, in a supportive role to the Haitian staff. His thoughts are his own and he does not represent any NGO.


World Policy - Generally, what is the status of the public health systems 'on the ground' in Haiti now?

Christopher Dayton - There is a greater presence of Haitian staff at HUEH than I had seen at 2 weeks after the earthquake. For example, the Emergency Room had been staffed since the earthquake until the end of May by international workers. At that critical time, they stopped working the Emergency Dept at night in effort to reengage the Haitian staff and for training of new staff (HUEH is the training hospital for Haiti).

It was a difficult transition, but by June Haitian staff was present and provided care for patients at night in the Emergency Dept. From what I could tell and from questioning Haitian staff, it appeared that the Emergency Dept at night is now what it was like prior to the earthquake. Yet, observing the Emergency Dept at night from the ICU where I was, the care in the Emergency Dept was not to a standard that I was comfortable with. There were multiple complications that could have been prevented with more supervision, training, timeliness and resources.

There is a frustration within the Haitian staff towards their institutions that limits their motivation for innovation, improvement, and excellence.

For example, I remember speaking to an excellent Haitian doctor-in-training with whom I had worked a few times during my stay. She was looking for the gloves that the international NGOs had been providing to the hospital. Previously gloves had to be bought by patients' families from a pharmacy if a nurse or doctor needed them. I told her the gloves were running out as I showed her where the dwindling supply was; They were running out because the NGOs were having fewer supplies delivered as they were preparing to pull out of HUEH. I told her that the hospital needed to find ways to provide its own gloves in a sustainable way, that there was potential for improvement of the previous system of supplying gloves. She said something to the effect – “Nothing will change here.” Here was a young sharp Haitian doctor-in-training paralyzed with frustration at the hospital. Multiple similar experiences lead me to believe that there is little hope from within the institutions that there will be significant improvement from the inside.

WP - The international community has given millions in aid, how is the money being spent between the government and foreign NGOs?

CD - Much of the aid that went to the NGOs I went with paid for medical supplies, room & board and transportation for international medical staff. I asked around where the money to the hospital was going to, and It seems that most was being paid to the Haitian staff for the hospital. Yet there had been significant delays in the paying of these staff (with threats of strike) despite apparently available funding. I have heard that an NGO may have taken up the responsibility of ensuring adequate and timely paying of staff at HUEH. This occurrence alone would dramatically improve morale, security, and retention of Haitian staff at the hospital. Delays in receiving pay is not new to HUEH staff, it was a regular occurrence prior to the earthquake, yet another dysfunctional aspect of the national institutions.

I cannot comment on the government's ability in spending aid except for what I have already said in the delays of payment of Ministry of Health staff at HUEH (HUEH is a government hospital).

I can say that from my experience with the Haitian people though is that they trust international NGO's generally much more than they do their own government.

 If this is true, which I think it is, it is hugely problematic in a way that I can see no easy solution. NGO presence seems to weaken the Haitian ability to govern and provide for its own people. Yet, the conditions are so dire that NGOs rightly feel compelled to provide for their beneficiaries ... and the cycle continues.

WP - How effective is the collaboration between the government and NGOs?

CD -The collaboration between the Haitian Ministry of Health and the NGOs that I worked with was good. The departure of international staffing from parts of HUEH was well communicated, and though transitions were difficult, they proceeded as planned. I think this was related to the purely supportive stance that the international NGOs at HUEH took during May and June. During this time, administration of the hospital was completely left to the Ministry of Health staff. NGOs provided advice, support and updates of available resources to the existing Haitian institutions. This was a change from immediately after the earthquake when no administration was functioning and NGOs had taken more executive roles.


USAID image

WP - What is being done to ensure that the Haitians can take over once aid and emergency workers leave?

CD -There is a huge vacuum where the government should be. At HUEH, this creates an ethical dilemma concerning continued care of patients. Ideally a slow transition would be ideal where leaving international staff would work side by side with Haitian staff providing a gradual increase in responsibility and amount of time on duty while simultaneously educating; International staff would then leave as they become unnecessary. In HUEH, this transition never occurred despite NGOs attempting to coax administration and staff to work side by side.

There are multiple reasons why this didn't occur. First I think the language barrier was most important (despite the use of translators). Second, the frustration and lack of hope for improvement by the Haitian staff led them to minimize efforts - especially if their hard work in a period of transition might lead to the departure of the helpful NGO staff. Haitians do not want to see the NGOs leave; this would mean a decrease in resources and a lower level of care. As a result, NGOs had no choice but to warn the Haitian administration and staff that they were leaving, and then do it. Thankfully, Haitian staff did step up and bring the level of care at least to a level close to pre-earthquake.

WP - How can this rebuilding be used as an opportunity to restructure and improve Haitian health care?

CD - I am hopeful but sober. For example, we left a functioning ICU and four ventilators for the Haitian staff to use. Because there was not a true transitional period with the international staff, the Haitians did not receive education in critical care practices nor were they able to learn how to use the ventilators. I also know that there were maybe 10 dialysis machines donated to the hospital a few weeks after the earthquake by a departing NGO that were not being used at all by the dialysis staff 6 months afterwards.

Still, I think these attempts are better than nothing. I have hope for institution and resource development that is directed more through the Ministry of Health than parallel to it (of which the dialysis machines and ventilators are examples). Maybe through the paying of Ministry of Health salaries effectively, confidence might grow in the institutions that may lead to further internal improvements. I think these changes will take a great deal of time in order to erase the negative short and medium term memory of Ministry of Health doctors and staff.

WP - Now that the press has largely left Haiti it’s hard to get a view of what's really going on, both in terms of the policies of the international donors and the Haitian government, but also of the everyday realities there.

CD - It is true the media coverage has largely left. The questions of safety to international NGO personnel and media have persistently forced most people to limit their contact with the day to day realities of Haitian life, especially in Port-au-Prince. 

Even at its best, media has only been able to give glimpses of the Haitian story.

In all my visits, I was very limited to where I could go, to the extent that I only saw Haitian life from the perspective of the patients I cared for. I imagine those working with other NGOs or for the government also are not able to get a good grasp of the full and graphic picture of Haiti. To some degree I think we don't want to know. The lack of mutual understanding of the conditions in Haiti might lead to a possible dyssynchrony between the Haitian government the numerous NGOs roaming the streets of Port-au-Prince. The sheer number of different logos on Toyota SUV's makes you wonder how there could not be.

--Nestor Bailly conducted this interview for the World Policy Journal website.

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HUEH (June 28 - July 7th) A RN's Reflections, those of her own and not of any NGO's. - Assigned 6 member Team Task: Last minute change of bedside clinical focus to assessing systems we felt we could have a positive impact on based on our areas of expertise, make recommendations and to provide some education. The NGO's time on site was limited and NGO clinical weaning was in its final phase. System Improvement is my area of expertise. The reality was however, the rawness of avoidable misery, avoidable complications and death paralyzed my systems thinking. Anyone who knows anything about systems improvement knows you must understand the front line current process and challenges before making recommendations and pulling teams together to consider those recommendations. Day 1 as I began to venture into their reality of HUEH health care, humans literally begged for immediate clinical interventions and partners. Day 1 it was apparent intentions to be introduced to administration were not genuine. After Day 1, my personal ethics would not entertain the idea of independently seeking out an air conditioned office upstairs to discuss systems when downstairs in the open Emergency setting an ongoing medical crisis existed - no basic airway interventions (and I mean very basic such as turning seizing patients on their side), no immediate standby oxygen in the department, no suction, no running water, no linen (unless you were dead you received a clean sheet), no bedpans or urinals (buckets instead), naked young man handcuffed to a bed railing for days, naked woman huddled in a corner for days,(no psychiatric support), patients observed restrained with rope,(truly cow tied hands and feet at times), no rescue squads, people brought in by car, carried in and laid on the floor by desperate families, no support staff,(if you had no family present you were truly left alone), starving thirsty patients, periods of darkness at night, periods at night with no medical or nursing staff in the department, severe pain and downright misery. Shortly after arrival I had two statements I would say to myself numerous times a day to maintain sanity: 1) I see dead people (yes, from the movie The Sixth Sense) and 2) I can only do so much with so little. Haitian medical and nursing staff continue to live this nightmare as I write these words. But it is the Haitian patients and families themselves, who are an unbelievable faithful, honest, appreciative people who suffer the most. I have struggled with myself wondering if in 8 days I could have made more of a lasting impact that would stick, focusing on systems with administration. Day 1 thinking that opportunity would occur was rapidly replaced with awareness that there was probably never a real intent for that to occur by leadership. Truly I believe now that there was no real belief that anything positive system wise could be accomplished in that period of time - by an "outsider" who would be leaving shortly. What I do know, is there are patients and families and professionals who experienced positive clinical outcomes as a result of our team. That sticks, even if only with a few. I will go back to Haiti again. Port au Prince was my second trip since the earthquake. My February medical experience was a rural one. What I learned about 3rd world systems is it takes a partnership. I can focus on systems when I know my clinical partner is able to meet the immediate need of partnering with Haitian professionals focusing on saving lives and relieving misery. This gives hope to Haitian professional partners. If there was ever a question of which was most important to me in my career, administration or clinical work, this experience answered that question. When thrown in the deep water, you have to swim unless you have support. I really think it's all about the financial infrastructure planning and implementation, or lack thereof. The real question is who cares now as countries are drowning in their own financial problems and new disasters occur. You can make a difference once person at a time we if all do it regularly. k
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