Cange is a small town on Haiti’s Central Plateau. It is well-known in global health circles for the pioneering work of Boston-based Partners in Health (PIH) and its Haitian sister organization Zanmi Lasante (ZL) in developing effective novel strategies for the management of HIV and multi-drug-resistant TB (MDR-TB) in work begun over 25 years ago. The work of PIH co-founder Paul Farmer and the program developed on the Central Plateau was profiled in Tracy Kidder’s 2003 book “Mountains Beyond Mountains,” based on the Haitian proverb dye mon, gen mon (“beyond the mountains, more mountains”); i.e., always more work to be done, always additional problems to solve, always more illnesses to treat…
While the HIV and MDR-TB challenges forced their way to the center of PIH’s early efforts, Dr. Farmer and his colleagues were intensely aware of and built their healthcare delivery model within the context of the “global” needs of Cange and the Central Plateau. They understood that successful HIV and MDR-TB management had to also account for the entire community and all of the inter-related healthcare necessities, structural deficiencies, and socio-economic inequalities that magnified the regional population’s burden of disease. A successful program, therefore, had to necessarily include water and sanitation issues, immunization programs, malnutrition and food insecurity, maternal/child health, and access to general care.
As general care clinics developed, patients with conditions requiring surgical intervention began to present in ever increasing numbers and a program was developed to provide basic general surgery services. Though there was no facility in Cange originally designed to accommodate surgery, a 2-room area in the small Clinique Bon Sauveur was designated as an operative theater.
I was introduced to the late Dr. Josue Augustin, Zanmi Lasante’s director of surgery at the time, in 2006. He invited me to work with PIH and ZL to develop an otolaryngology service based at Clinique Bon Sauveur. Dr. Augustin and ZL had just recruited Dr. Phoebee Jovin, a newly trained Haitian otolaryngologist, to work in Cange one week per month. Dr. Jovin began seeing scores of patients in the ENT clinic each week she was in Cange, taking selected patients to surgery. Initially there was no dedicated ENT clinic space or instrumentation suitable for most operative procedures including major ear surgery, sinus surgery, and microlaryngoscopy. Working with Drs. Augustin and Jovin, we were able, over the next 2 years, to establish and equip an otolaryngology service that began to provide more predictable ENT coverage and better continuity of care for general pediatric and adult care. (Dr. Jovin was on site the third week of every month; I traveled to Cange 2 to 3 times per year to assist with clinic and perform major head and neck procedures triaged to my visits). Dr. Jovin, assisted by on-site Haitian general surgeons, also provided follow-up for complex head and neck surgical cases. Over the last several years, our program has successfully developed a small cadre of American-trained, academically-oriented otolaryngologists who have worked in Cange with Dr. Jovin and me and who remain dedicated to continued development of the program.
Overall, the program has been successful in establishing a specialty service in a region that had none seven years ago. With the support of PIH and ZL, we have been able to collaboratively establish continuity of service that stands in contradistinction to the historical “mission model” still prevalent in global surgery. The collaborative effort has included clinical support and consultative services from PIH-affiliated pathology, radiology, and oncology staff associated with institutions such as Brigham and Women’s Hospital and Boston Children’s Hospital, among others. Additional continuity of service includes fairly regular internet-based patient consultations, triage, and care coordination.
Although many obstacles have been overcome and challenges met these last several years, the otolaryngology effort has been successful primarily as a proof-of-concept delivery model for continuous specialty surgical care in a resource-poor setting. We have demonstrated that with a sustained collaborative effort involving well-established partners (PIH/ZL) and dedicated Haitian clinical counterparts continuity of surgical care is possible. However, we are still a great distance from achieving our long-term objective of assisting our Haitian colleagues in developing a more holistic program “in perpetuity,” by and for Haitians, which includes structured transfer of surgical skills, development of surgical infrastructure, guidance for professional and administrative development, and research tools for assessing outcomes and effectiveness, among other measures. Additionally, and notwithstanding the central role of NGO’s such as PIH and ZL, growing and sustaining a developed-world model will of necessity require the participation and support of the Haitian Ministry of Health (MOH). Haiti’s national public health programs are centralized in the MOH and a significant proportion of international donor funding is directed to the MOH in support of such efforts.
There is one Haitian national otolaryngology training program based in Port au Prince at the University Hospital of Haiti (Hôpital de l’Université d’Etat, HUEH). The hospital was severely damaged in the 2010 earthquake and planned reconstruction is well behind schedule. I had the opportunity to meet and discuss the national ORL residency training program with its director Dr. Jean-Claude Cadet in 2006. Even in the pre-earthquake years, the program was significantly constrained from being fully-realized largely due to difficult access to scarce resources and degraded infrastructure. For example, although ORL clinics at HUEH were exceptionally busy, access to the operating theaters was problematic due to limited supplies and availability of anesthesia services. These restrictions not only impaired the program’s ability to address the burden of head and neck disease but also limited surgical skills transfer to the residents in training.
The devastation from the earthquake in Port au Prince and its impact on HUEH prompted a general re-assessment of pre-quake infrastructure plans for improvement of the healthcare system. One specific example of re-direction is the story of the recently completed Hôpital Universitaire de Mirebalais (HUM; http://www.pih.org/pages/mirebalais). Mirebalais, a Central Plateau town on Highway 3 between Port au Prince and Cange, was slated for construction of a community-type hospital prior to the earthquake. With the extensive damage to HUEH, and related loss of healthcare capacity, as well as uncertainty about the feasibility and timeliness of reconstruction, numerous public health stakeholders including PIH/ZL, the Haitian MOH, international foundations, countries, and corporate entities worked together to re-vision the Mirebalais project as a key regional tertiary care model medical center. The Mirebalais facility opened in April 2013 as a 300-bed, 6-operating room facility with capacity, when fully operational, to support 500 ambulatory visits per day and serve all of central Haiti including areas in and around Port au Prince. The medical center is expected to fill a huge void, locally and nationally, for people who previously had limited access to quality health care. Additionally, the center will eventually serve as a training facility for Haitian nurses, medical students, and resident physicians, including those from the national ORL program currently based in Port au Prince.
Regarding the otolaryngology program currently in place on the Plateau, the availability of HUM offers the opportunity for the Program in Global Surgery to collaborate with the Haitian national otolaryngology residency program, PIH/ZL, the Haitian MOH, and other stakeholders in developing a robust clinical and academic training paradigm with the ultimate goal of a self-sustaining, Haitian led program.
Seizing and fully realizing this opportunity will require a resource-intensive, concerted effort involving numerous stakeholders working collaboratively over the long-term. The challenges will be numerous and chronic; problems ranging from governance to clinical management to outcomes assessments will have to be solved along the way. In considering the prospects for success of this endeavor, it is reasonable, given the Haitian context, to reference another Haitian proverb, Nanpwen malady ki pa gen remѐd (“There is no illness that does not have a cure”).
Robert Boucher, MD, MPH