Tuesday, July 13, 2010

Cost of Chaos Measured in Lives

Photo by John Carroll
May, 2010
Pediatric Tent, General Hospital

In May I walked through the General Hospital complex in downtown Port-au-Prince. It is a huge complex (a square city block) with many medical buildings surrounding a courtyard with a pretty blue and white church in the courtyard. A morgue sits in the back corner.

I had been to the General Hospital many times in the last three decades and it looked just as bad as ever.

I had worked in the Pediatric department in the past evaluating children with heart murmurs to determine if they were candidates for heart surgery in the United States.

The ancient Pediatric building (which had been built by the American Red Cross decades ago) had significant damage and a large crack running through the front wall. The building obviously was not safe to have patients inside. So the pediatric patients had been moved outside into large tents on the road in front of the building.

The tents were filled with babies in tiny cribs. IV's dripped fluid into their veins and some babies had oxygen via nasal prongs or oxygen masks.

The tents were very orderly but extremely hot inside. I wondered about all of the "insensible" fluid loss the babies were having in the sweltering tent heat.

In one of the tents a Haitian pediatrician sat at a desk in the corner recording a history on a new admission. Fans were running at full bore but circulating warm humid air.

In these tents, mothers sat attentively at bedside with their sick little ones. And when water was needed, the mother or other family member went outside to a giant blue cushion that looked like a huge water bottle. It was filled with water. I think the UN had donated this cushion and filled it with water. There was also an intricate appearing spigot system near the blue cushion that provided access to the water.

Just a few feet down the street which coursed through the General Hospital medical complex was a field filled with debris. A smashed red van sat on the edge of the field. This area had a nursing school and dozens of young nurses were killed in the horrible 47 seconds on January 12. It made me sad to look at this vacant spot and think of the beautiful young Haitian women that died instantly as they were pursuing their nursing degree that horrible afternoon.

The General Hospital Emergency Department was still functioning in its original pre earthquake location and was somewhat busy, but still not as busy as it should have been in a city with three million people without basic services.

I saw many foreign nurses who seemed to be "running the show" in the Emergency Department. I did not see Haitian doctors or nurses working inside the Emergency Department, but I may have missed them too. And as Jonathan Katz's article below clearly states, it would be nice if the General Hospital doctors and other hospital personnel were paid their fair salaries.

But this is not a new story either. Haitian resident physicians that do the majority of the work at the General Hospital over the years, have frequently not been paid their salaries by the State of Haiti. And Haitian doctors have gone on strike multiple times in the previous decades because they have not been paid. And patients have died. And several years ago their bodies were piled on the sidewalk in front of the General Hospital as a form of protest by the doctors and hospital employees.

Can you imagine American doctors in the same situation? Would we continue working?

And when doctors who don't get paid for months go on strike and the hospital shuts down, who is at fault? The doctors or the State?

Today is July 13, 2010. And Haiti is in big trouble.

I am working in a clinic in southern Haiti and people are very sick here. The medical system is sick and so is Haiti's infrastructure.

Name a problem and it is here.

I examined a 14 year old girl today who is an inpatient at the clinic. Her father is dead and her mother is home in a town down the coast with her seven siblings. She has no family or friends at her bedside. And she is 14 years old. She needs someone and she needs a system to look after her.

See Jonathan Katz's article below. He writes that the "cost of chaos is measured in lives". This is true. But so much of the chaos doesn't need to be. Hospitals and medical clinics need to have the basic technology and hospital personnel need to be paid fairly.

Haiti Struggles With Ongoing Hospital Woes
Overall, Haitian Medical Care Better After Quake

JONATHAN M. KATZ, Associated Press Writer
Posted: 4:45 pm PDT July 10, 2010
Updated: 12:32 am PDT July 12, 2010

Haiti Hospitals Show Recovery Challenges

PORT-AU-PRINCE, Haiti -- It was a simple problem with a novel solution.

Doctors, nurses and technicians at Haiti's most important hospital had not been paid since before the earthquake - causing strikes and staffing shortages, and turning the facility into a dangerously inefficient, rat-infested mess. So in March, the American Red Cross volunteered to donate a small part of the $468 million it raised for quake relief toward supporting their salaries.

But the $3.8 million promised to the hospital is only now being delivered after four months of negotiations and red tape. While billions were spent on short-term projects, including medical assistance, doctors' strikes continued and neglected patients at the capital's main medical facility were left to suffer and die.

The breakdown at State University Hospital is a prime example of the difficulty in grinding out a successful recovery. Six months after the magnitude-7 quake leveled much of the city and turned the hospital's courtyard into a grisly open-air morgue, promises to help Haiti become more self-sufficient have produced often frustrating results.

"The intent is there. The money is there. It's just that these are complicated issues," said Louise Ivers of Boston-based Partners in Health, which acted as an intermediary between the Red Cross and the hospital.

Sources involved with the project say the problem came down to clashing styles, needs and timetables. Haitian hospital administrators were trying to please government officials and satisfy angry employees while maintaining control of their institution.

The Red Cross, meanwhile, was trying something new: Disaster relief funds rarely go to fix up local institutions, especially ones run by the government. Doing so required heavy auditing and learning a new set of rules for operating.

The organization is proud of the project. Nan Buzard, the American Red Cross' senior director for international response and programs, said the infusion of money is an essential stopgap measure for Haiti's medical system.

"We really think this is one of the best things we can do," she said, adding that she understands doctors' frustrations given how long it had been since they were paid.
Former U.S. President Bill Clinton, who is helping oversee reconstruction, said in a Saturday interview that his staff worked hard to see the agreement through - in large part because it might encourage other donors to support existing but foundering Haitian institutions.

"It took a while for it to get together, but we were working very intently on this," Clinton told The Associated Press by phone. "This is a little bit of a departure from what the Red Cross or other NGOs have done in the past. When you're trying to change all these cultures, it's really something."

But at the hospital, frustrations are running high. Unpaid staff have little incentive to work - passion for helping those in need can only take them so far. Cleanliness, thoroughness and efficiency fall by the wayside.

For a hospital in rundown Port-au-Prince, where public sanitation is nonexistent, that means horror show conditions. The operating rooms are not sterile, and doctors say vermin sometimes run through during surgery. With much of the building damaged from the quake, patients endure long waits for overworked doctors in hot, flimsy tents that offer little protection from the elements.

"We are back to running this hospital as before the quake," said its executive director, Dr. Alix Lassegue. That does not mean, he quickly added, that there is an acceptable standard of care.

Until the Health Ministry prepares and presents a master plan for improving conditions to the interim reconstruction commission led by Clinton and Prime Minister Jean-Max Bellerive, that is unlikely to change, Lassegue said.

Yet it is one of the ironies of Haiti's reconstruction that medical care on the whole is better in the impoverished country now than before the quake, thanks to a flood of volunteer doctors, nurses and equipment.

But the promised leap from emergency aid to long-term viability for the medical system has not happened. Aid groups, once massed at the hospital in central Port-au-Prince, have left. The last group abandoned rooms of equipment and a filled-out white board.

Reginald Cadet, a 26-year-old first year medical resident, said that until paychecks show up regularly, he and his colleagues will be forced to continue intermittent strikes. He started working at the facility in May and has not once received his $150-a-month salary.

Still, he does not want to work anywhere else. "I'm a doctor. I always had a dream to be here," Cadet said.

The cost of the chaos is measured in lives.

Recently a 28-year-old woman was brought in with vague symptoms including fatigue, recalled Dr. Megan Coffee, an infectious disease specialist volunteering from San Francisco. The doctor ordered tests, which lab technicians took three days to produce.

The woman, whose name was not disclosed for confidentiality reasons, had failing kidneys. Emergency dialysis would save her life. Without it, she would die.
But there were too many patients who needed dialysis and not enough equipment or doctors.

The woman's body began to fail. Realizing help would not come, the family took her home. They called within hours to say she had died.

If support like that of the Red Cross would come, such tragedies could be avoided, Coffee said: The hospital has the expertise, and her Haitian nurses have the dedication.

"They just need to know that their job will support them," Coffee said.

Copyright 2010 by The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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