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Tuesday, March 29, 2011

Haiti and the conundrum of being merciful without enabling dependency

I just got back from 2 weeks on the Haitian island of La Gonave. We have a longstanding exchange established between our community in Idaho and several communities there.  Last year, a few months after their earthquake, I visited for the first time, carrying medical supplies and planning on delivering care to the injured and ill. In fact there were very few injured and ill, partly due to the fact that La Gonave is very rural and few houses were occupied at the time of the quake. The other important fact was that this part of Haiti, with few if any medical providers, does not support sick or injured people very well and so they either die or recover.

This visit was primarily to study their medical resources, beliefs, health concerns, and to advocate for better sanitation practices and water antisepsis. I was unable to resist bringing medications and supplies, and also stuffed my suitcase with condoms to hand out like candy.

Community organizing around effective ways to use their medical resources went well.  They have traditional healers who know herbal medicine which is reasonably effective for common woes which are related to pain of the physical or psychological variety.  Health agents have access to some medications and administer vaccines provided by large NGOs such as World Vision. Coverage is far from complete. Physicians, like me, sometimes come and give workshops, and one community said that standard information about maternal and child health really made a difference in infant mortality. All mothers deliver their babies at home and many are without an experienced birth attendant. There are no doctors save the occasional foreign visitor and one or two who provide coverage at the main hospital in the port town of Anse a Galait. Truly dire situations can sometimes be taken care of in that hospital, but transportation from most of the other communities is by the rare truck or by motorcycle, and can take hours over very rough roads. The care is not free, and although a non-paying customer might get emergency care, a debt will be incurred. I pushed community members to pay their providers, even a little bit, send their children to become nurses or doctors, improve sanitation including toilet technology and water treatment. Midwives and traditional healers need to work together and could potentially become more skilled by working with visiting practitioners. These approaches are all possible and community members were receptive.

I enjoyed talking with people about the use of condoms, blowing up condom balloons and demonstrating appropriate techniques on locally available bananas, and I think the people I spoke to really appreciated the talks and the free condoms.  Still, many Haitian women believe that a condom, if it breaks, can get lost in the body and kill a person, that many women will be allergic to them and that they are in other hard to define ways more dangerous than unprotected sex. AIDS is quite common in Port Au Prince, a quick ferry ride from the island, and at least one woman with unmistakeable symptoms of HIV stopped me on the road to ask what was wrong with her, having had swollen lymph nodes since the birth of her baby 14 months before. HIV testing is not commonly available and people are so concerned about the stigma that most would not get tested if it were available. Treatment is available through hospitals on the main island, free of charge, but for many people the disruption of their families would make this impractical. Condom use in La Gonave is about as common as it was in the US before the advent of AIDS and a vibrant women's rights community can probably push the acceptance of this technology in the right direction relatively quickly. The international community is eager to provide condoms once there is demand.

Medically speaking, rural Haiti is a bottomless pit of need. Like all bottomless pits, endless resources will not be enough. Despite having the highest (or second highest, depending on what figures you use) ratio of NGOs per capita, most rural areas are not significantly improved in terms of medical care, sanitation or other safety nets. La Gonave is mostly unaffected by NGO presence, other than having a flourishing crop of evangelical churches, which do provide a social structure and usable community meeting spaces. There are nicely constructed "formularies" with medications and examination room spaces, educational posters and almost no staff. These have potential in terms of healthcare delivery but are presently almost useless. Bringing adequate medical staff to La Gonave, supporting them and maintaining a presence would be incredibly expensive, and with the present infrastructure on the island, with almost no resources for most people to make money, transitioning such a program to being self-sustaining would be very difficult. A reasonable alternative to an American style medical system would be to focus on prevention. The most life-shortening diseases in La Gonave are diarrhea for children, injuries for the young men, childbirth for the young women and hypertension and diabetes for older folks, mainly women who become overweight when their children are able to do the heaviest chores. All of these conditions are preventable. Life expectancy in the US increased by 30 years in the last century, of which 25 years can be attributed to public health measures, such as sanitation and injury prevention.  The present life expectancy in Botswana of 36 years would be over 70 years without AIDS. These figures suggest that community organization to prevent disease in La Gonave would dwarf the effects of having an adequate supply of capable medical providers. 

So why, then, did I bring a bag full of drugs and medical supplies rather than entirely focusing on educational materials? It would have been easier. But the vision of being presented with a very sick person for whom a well chosen antibiotic or other intervention would save a life and being unable to help was unimaginable. I did hand out a few drugs which might have made a difference, but generally the problems I faced were either minor or incurable. Still, I kept flashing back to the story of the little kid throwing stranded starfish into the ocean, arguing "it mattered to that one."

And still I wonder if much of the direct aid being delivered to Haiti, that which is delivered, which is a precious small percentage, is really doing anything positive. Most of the people I spoke to in La Gonave were focused on what I could give them, despite the fact that they have been failed repeatedly by aid organizations, and remain crippled by dependency. Is the provision of free money not simply fostering the economy of desperation that keeps people from being able to shift into self-sufficiency, however slow it may be?

Another metaphor for this is the puppies of La Gonave.  The four of us who traveled together (an artist, a teacher, a plant pathologist and me) stayed at houses with families. At each of our houses were dogs with puppies. The dogs were docile, good barkers, gentle with children, chickens and cats and much more bone than flesh. They were fed almost nothing and drank only when they could find wash water that had puddled somewhere. The puppies were also incredibly cute, but slowly dying of starvation. Every one was completely eaten by fleas. They had no names. As a connoisseur of puppies, I was captivated by the idea of shampooing one, feeding it well, eradicating its parasites and taking it home. It was pretty heartbreaking. But puppies in Haiti cannot all survive. There are about the right number of dogs right now, and with no doggie birth control, each female will probably have more than one litter a year, so without adequate control of fertility, incredibly cute puppies must die. The kindest approach, without spaying and neutering technology, would probably be some sort of selective female puppycide, which would be heartbreaking as well. In La Gonave they appear to have chosen starvation as the method of population control. Did I feed the puppies when no one was looking? You bet!

In reviewing this trip, however, I come to the conclusion that mercy is human and irrational and wonderful. Mother Theresa in India not only ministered to the sick and dying but provided an example of kindness in a place where it was often in short supply. (She also neglected to support birth control and condom use, but that is not part of my point.) I am glad that people are kind and give hope to the hopeless. I love puppies. But I think I will focus even more on prevention if I go back to La Gonave next year.

Wednesday, March 2, 2011

Practicing good medicine by paying attention to the patient

I just read an article in the New England Journal of Medicine by Sean Palfrey MD, a professor at Boston University School of Medicine in the department of pediatrics.  Dr. Palfrey dares to state the obvious, in a world in which the telling it like it is can be the kiss of death.  Dr. Palfrey writes:

Every participant in our health care system must focus on ways to optimize health while decreasing cost, at every step of the process. We need to change the financial incentives currently embedded in health care reimbursement systems that reward the use of tests, procedures, consultations, and high-cost therapies. And finally, the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn.
These are major changes, but today we are far from providing good care for all our citizens and far from achieving health care equal to that in many other countries. We need to incorporate more realistic clinical, scientific, and financial information into practice in order to bring our health care practices, and our health care system, back into balance.
Thank you, Dr. Palfrey. The reason that this opinion is so unpopular among politicians is that it brings up the specter of doctors mistreating or ignoring the suffering of patients in order to save a buck. This is an issue that must be recognized and dealt with in an era when practicing cost effective medicine will be the only practical path. Good medicine and attention to costs can go hand in hand if the physician truly takes the time to listen to the patient and think about the diagnosis. Further, inexperienced doctors need to be able to use the wisdom of experienced colleagues, either by formal or by informal consultation, which requires time and good communication. In many cases, the approach that involves more testing, more complexity and more treatments saves a little bit of time in the short run, wastes a whole lot of money, and leads to more time wasted and poorer patient care in the end.