Tuesday, March 06, 2012

Ministry of Health Disaster in Haiti

Pediatric Cholera--Photo by John Carroll

Early today in pediatric clinic in Cite Soleil I had a young mother bring in her 10 month old baby boy. She told me that he started having diarrhea yesterday. He had ten white watery stools yesterday and five similar stools this morning. He is drinking some and nursing some but clinically appeared lethargic and moderately dehydrated.

It was an easy diagnosis. I thought this baby boy had cholera.

Most of my pediatric patients in the clinic actually do have diarrhea. But this baby's diarrhea was different and his clinical presentation was consistent with cholera.

So what should I do?

The population of Soleil is estimated to be in the hundreds of thousands. But no one knows for sure. And before cholera struck Haiti in 2010, Soleil had the usual horrible diseases of poverty. Now it has had cholera added to its "differential diagnosis" . And the experts from around the world say that cholera will return here in a few weeks when the rainy season starts.

Is this baby the harbinger of the next wave of cholera?

Working in Cite Soleil as a physician is challenging. We all know that the people from the slum are suffering and dying from stupid deaths everyday. This is no secret. And intervening to help them is not always straight forward.

Soleil should not have a monopoly on medical helplessness and hopelessness, but it sure seems to.

I first worked at St. Catherine’s Hospital in Soleil in 1987. I had the opportunity to work with Dr. Paul Blough, a retired OB-GYN doctor from Peoria, Illinois. Dr. Paul delivered over 10,000 babies at St. Catherine’s in the 1980's and 90's. He was in his 70’s and 80’s when he worked in Soleil and he gave excellent obstetric care. And so did the Haitian midwives that worked with him.

The Daughters of Charity, who are an order of St. Vincent de Paul Sisters in Soleil, worked at St. Catherine's during those years too. The hospital functioned and many patients were treated every day.

Doctors Without Borders, which responds to "hot zones" around the world, has been running the hospital since shortly after the 2010 Haitian earthquake. But they left the hospital three months ago because their contract with the Haitian government expired.

Doctors Without Borders had an army of medical people including public health experts that tracked cholera in the Soleil slum neighborhood-by-neighborhood and street-by-street. Cholera tents were erected at St. Catherine's Cholera Treatment Center (CTC). These tents were away from the other post earthquake tents that housed general medical patients. Thousands of cholera patients were treated and many lives were saved.

And inside the hospital that was not damaged by the earthquake, Doctors Without Borders offered a small emergency room, surgery department, internal medicine and pediatric wards, and an obstetric unit.  Many patients from Soleil were operated because the surgeons, anethesiologists, and surgical nurses were on site.

Entrance to St. Catherine's Hospital Cite Soleil

But all has changed. St. Catherine's is no longer bustling with activity like it should be in this huge destitute slum.

Ministre de la Sante Publique et de la Population (MSPP), which is the Haitian Ministry of Health, is in charge of St. Catherine's Hospital now. MSPP has government hospitals in each of Haiti's ten departments. However, they don't function well.

St. Catherine’s is in terrible condition now. It is staffed by a tiny handful of excellent Haitian doctors employed by MSPP, but the hospital has very few medical supplies.

And there is a new problem.

Patients are now charged five Haitian dollars (75 cents US) to have a check up. And if they need to be admitted to St. Catherine's they are charged two hundred Haitian dollars (25 dollars US) for a bed. Doctors Without Borders did not charge.

Patient's families have to provide the sheets for the bed and food for the patient. And family members bathe the patient and empty the bedpan.

Medical supplies and medication are provided by the hospital if they have them. But if they are not available, the patient's family has to try and buy them somewhere on the street which is frequently impossible to accomplish. (How would you buy 4-0 chromic sutures?)

So lack of money stops people from coming to St. Catherine's in Soleil in the first place.

The hospital has very few patients right now. With Soleil's population, there should be patients everywhere. The three stretcher Emergency Room is usually empty of patients and staff. It has one tall narrow cabinet with some medications to treat infectious diseases and hypertensive emergencies.

The General surgery ward at St. Catherine's is competely closed as are the operating rooms. There are no surgeons or anethesiologists.

The Obstetric ward is open and seemed to have the most patients of any inpatient unit. And C-sections can be done under a spinal...but only when a nurse anethetist and an obstetrician is present.

Internal Medicine Ward--St. Catherine's Hospital (Photo by John Carroll)

The Internal Medicine ward has a smattering of a few ill elderly people. There is no oxygen to give patients in respiratory distress and very few medications. It is very depressing to see the elderly lying about sick and in disarray.

The Pediatric ward has a few patients but they should have many more. There are many sick kids in Soleil. St. Catherine's has three Haitian pediatricians employed by MSPP that run an outpatient clinic at St. Catherine's for a few hours Monday-Friday.  And these same three physicians admit the sick babies who they think they can manage in the hospital with its meager supplies and technology.
Pediatric Ward, St. Catherine's Hospital (Photo by John Carroll)

So what does all this mean?

It means that St. Catherine's Hospital, run by MSPP, is offering very inferior care to hundreds of thousands of people from Soleil who become sick or who are injured.

How does this scenario play out on a day by day basis?

Let me give a couple of examples.

A few days ago while rounding in St. Catherine’s Internal Medicine ward, I spotted a sweet appearing old lady lying in a corner bed. Her name is Famia and she is 72 years old.
She had three interested family members seated near her by her bed. Famia was alert and had a very kind appearing grandmother type of face.

I asked her what was wrong. She said that she had been given a shot in her left buttock five days prior and develped a problem.

Famia rolled over and showed me her massively swollen and tender left gluteal area. Her buttock and thigh were red and warm to touch all the way to her mid thigh. There were ominious appearing purple patches of skin over the buttock. She obviously had a very infected buttock and and thigh and needed surgical debridement and antibiotics to have a chance at survival.
Famia's Infected Thigh (Photo by John Carroll)

However, Famia was receiving no IV, no antibiotics or pain meds, and there was no operating room or surgeon waiting to help her. Her leg was septic and she would be too if nothing was done very soon.

I told her that I would pray for her and slowly backed away from her bed not knowing what to do here in Soleil with more neglected slum pathology. Famia had impending death written on her forehead.

I walked to the pediatric ward with Famia on my mind. Prayer is most important, but is that all I could do. What about "works"? There had to be more that we could do here and right now.

And then it dawned on me...why not transfer her? I have a good friend who is a surgeon in private practice in Port-au-Prince, and her number was on my cell phone.

So I called her immediately and she was accepted over the phone right away. I rushed back to her bed, gave her family members the address to the private hospital and surgeon and some money for public transportation and they said they would take her.

Famia made it there and is being treated...I don’t know if she will survive, but her chances at survival in Soleil were zero. And none of this was necessary if St. Catherine's was functioning at a basic level like it should be. ( While posting this, I just received an e mail from the private hospital director stating that one of his surgeons is taking care of Famia and she is doing well.)

And on a bigger picture, what will the people of Soleil do when the rainy season starts and cholera starts infecting them again?

St. Catherine's is going to triage people with cholera AWAY from St. Catherine’s to CTC’s because they have no intention of treating cholera like Doctors Without Borders did during the last two years. Patients will be sent to the small CHAPI health center near the entrance of Soleil or to some other CTC somewhere in PAP run by NGO's. (Hopefully, Samaritan's Purse will reopen their 200 bed CTC in Soleil if necessary.)

And what about my baby in the clinic with cholera yesterday? The baby was still alert enough to take fluids by mouth, but with the weekend approaching, I told the mother that she needed to take her baby to a CTC in the neighborhood of Delmas so the baby could have an IV.

Mother listened but she politely refused.

She knew St. Catherine's is right across the street and could not understand why she could not take her baby there.  And she said she would get lost in the Delmas neighborhood and would not be able to find the CTC.

So I reluctantly gave here some packets of oral rehydration salt and some money for transportation to Delmas if she changed her mind.

It would be easy to blame this mother. But we can't especially under the inhumane living conditions in Soleil. There is no structure here except hob-nob attempts at daily survival.

And guess what? Many more mothers in Soleil think the same way that this mother thinks. They have no money for transportation out of the slum and they have more kids at home to worry about.  So they have to do their own triage and decide which of their kids go to school, which kids eat, and which ones get medical care. They have to pick which children will live and die.

I recently talked to an official for MSPP in downtown PAP. I specifically asked the official why things are so atrocious in MSPP run hospitals. The official said that there is not enough funds dedicated to MSPP for anywhere in Haiti, let alone Cite Soleil. The official said there is not the “governmental will” to allow MSPP hospitals to function at a higher level.

This leads us back to money again. Where is all the post earthquake billions of dollars of pledged money for Haiti?

I can sure tell you where it isn't. It is not at St. Catherine's Hospital in Cite Soleil.

Neonatal Intensive Care Unit--St. Catherine's Hospital, Cite Soleil (Photo by John Carroll)

John A. Carroll, MD

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