A Focus on Mental Health
Following the 2010 earthquake that devastated Haiti, demand for mental health services spiked as millions coped with catastrophic loss. More broadly, the World Health Organization estimates that by 2030, depression alone will be the leading cause of disability around the world. With partners like you to thank, PIH clinicians have provided more than 3,500 patients in Haiti with the mental health services they need. And around the world, we’re working to deliver this high-quality care to the poor, vulnerable people who often need it most.
One person who has benefited from this work is Paul. When he was 20 years old, he began hearing voices—and soon, he came to believe demons were persecuting him. Eventually, Mainardi’s family took him to the PIH-supported hospital in Lascahobas, Haiti, where he began psychotherapy and received medication for psychosis. He soon realized his problems were medical—and received the health care that helped him to manage his symptoms and secure a happy, healthy life.
Paul was so moved by his experience that he wanted to share it with others and prevent the harm that can come from not receiving quality care. So he started a radio station in his home. He transmits messages over the airwaves about mental disorders as a treatable condition, and urges people to seek care from the mental health team at Partners In Health.
“In life, anything is possible,” he begins in one radio spot, in which he describes the range of clinical mental health services available in the community—community health workers, nurses, social workers, psychologists, generalist physicians, and, if needed, a psychiatrist.
The following article was published by Observer News on March 19, 2014. In this article, the author discusses the successes observed during his most recent trip to Haiti, including PIH's University Hospital in Mirebalais, made possible with your support to help build back better in Haiti after the earthquake.
Haiti Revisited, 2014
In nearly 14 years of witnessing the changes in Haiti, this trip was the first time I have seen real change.
By HAL OTT
Love. Hope. Determination. Pride. Extreme Poverty. Progress. Resilience.
These are but a few of the words that come to mind after my most recent visit to Haiti. I have been witnessing the ups and downs of the people of Haiti since my first visit to the country in April 2000. These people have suffered from corrupt governments and endured some of the most horrific natural disasters ever since they became free from slavery in 1804.
A gentleman in his sixties who moved to Port au Prince from a comfortable lifestyle in Canada told me once that Haiti was a “land of failed good intentions.” He explained that most of the aid going to Haiti was from churches and service organizations from the United States and around the world. People with the most loving and giving hearts bringing clothes, love, food, candy, beads and a labor force to build new churches, church schools and to feed countless starving children and adults.
For many years I was one of those Good Samaritans. And perhaps there is a need to fill a gap, to build hope and to provide food and a sense of belonging to something. Certainly, there was an urgent need to give them a leg up after the recent natural disasters.
But Jack Wall, the Canadian, and his wife, and now his daughter, taught me what Haitians really want. They do not want a handout. They do not want someone else coming to their country to tell them how to live and what to do or what to believe. For, in doing so, we help to create a country of beggars with poor self-esteem and a lack of dignity and self-respect.
The future of Haiti must be rooted in its people’s desire to be responsible, productive, participatory citizens. The rebuilding of their country must be in the hands of the Haitian people. Begin with what they have. Build on what they know. Work with them in their planning for a sustainable future.
In my nearly 14 years of witnessing the changes in Haiti, this trip was the first time that I have seen real change. I believe President Michel Martelly and his government have truly accomplished more to empower the people and to help Haitians to help themselves than in any other time in the past. New roads, bridges, sanitation, health care, foreign investment, jobs, a safer environment policed by the Haitian police — all are but a few of the advancements I noticed.
There is a rebuilding of the country from the bottom up and from the top down. This was the first time that I entered the country that the smell of burnt charcoal did not permeate the air. Reforestry projects are increasing. Small rural farmers are getting small loans to practice sustainable agriculture. Haitians teaching Haitians and helping one another.
I visited a hospital in the central mountainous village of Mirebalais. The hospital was founded by the renowned Harvard physician Dr. Paul Farmer. Farmer is perhaps the world’s foremost leader and expert on global health care for the poor.
Named Hospital Universitaire, the facility just celebrated its first anniversary. It employs 56 Haitian physicians, more than 100 nurses and approximately 700 other people, more than 99 percent of whom are Haitian. The hospital covers more than 200,000 square feet and is equipped with the very latest technology. It offers nearly all specialty areas, including infectious disease, surgery, obstetrics, ophthalmology, dentistry, cardiology and oncology.
It has more than 300 beds. The entire medical facility, including dorms for doctors and nurses, is 100 percent solar powered. The cost for admission for care is the equivalent of $1.25 per person.
It serves not only a local population of 185,000 but also special-care patients who travel from Port au Prince, a three-hour trip. Yes, to get the project built necessitated support from around the world, but it is a hospital built, staffed and run by Haitians for Haitians.
I also visited an urban gardening project in a very poor part of Port au Prince. There I saw Haitians teaching and helping their neighbors to grow their own food from seed. They use any container available — from the back casing of an old television to an old tire. Within 15 days, they can harvest spinach to feed their families. Any harvest left after filling the needs of their families is given to their neighbors. A sense of community and trust is built.
In this one project, more than 170 people were growing beans, spinach, cabbage, carrots, tomatoes and other food that was totally unfamiliar to me. It is a project developed by Haitians, owned by Haitians and managed by Haitians.
Don’t get me wrong. I have no false illusions about the challenges that this country faces. With the average age of a Haitian being 22, and 200,000 new people coming into the workforce every year, there is no quick-and-easy fix. But foreigners must recognize that the hand-out philosophy of past decades has not worked to rebuild this country.
With perhaps a million people willing and able to work, does it make sense for our high-school- and college-age students to go to Haiti to lay cement block for them? Will Haitians feel like they own that church or that church school that we foreigners have built for them? Yes, it makes us feel good about ourselves, but this is not a sustainable, participatory way to build a country of responsible Haitians with self-worth and dignity.
The empowerment of women is helping. Ending the myth that this beautiful island is not safe for tourists and foreign investment also will help. Sitting down side-by-side with Haitians who have a plan for a productive, participatory project and sharing with them ideas for them to reach their goals is, in my opinion, the best road to their future.
Four years after an earthquake struck Haiti’s capital—damaging its already-weak medical infrastructure—a new public teaching hospital in Mirebalais, Haiti,
A key function of the hospital is to train Haiti’s next generation of social justice doctors, nurses, and other health professionals. Workshops and trainings began before the first patient stepped foot in the building, but training has ramped up as specialty services come online. Since June, the hospital has hosted more than 165 trainings, including cardiac resuscitation training for 91 medical staff.
In fall 2013, the teaching hospital marked a significant milestone with the entrance of its first class of medical residents. These 14 young Haitian doctors are training to become specialists in pediatrics, internal medicine, and surgery, and a new class will enroll every year. Read more about this first enthusiastic class of residents here.
In 2014, hospital leaders will begin training for other specialties. Nurses will be trained in anesthesiology and critical care, skill sets that are necessary for emergency and surgical care. New medical residencies are being planned for obstetrics-gynecology, orthopedic surgery, anesthesiology, and emergency medicine, which would be the first such residency in the country.
“You don’t learn how to be a doctor in medical school,” said Dr. Michelle Morse, who has helped plan medical education programs at University Hospital. “It’s during residency that you dive in and begin to understand what it’s all about.”
University Hospital has also helped grow the economy of the Central Plateau.
Researchers from PIH, Haiti, and the United States teamed up to analyze the economic impact of University Hospital, using what’s known as an input-output model. They estimated that for every $1 invested in the hospital, $1.82 is pushed into the Haitian economy.
Essentially, the influx of resources in one sector of the economy—health care and teaching in this case—will affect other sectors of the economy through what’s called the “multiplier effect.” This will result in an economic impact far greater than that of the original investment.
“The idea behind the input-output approach is intuitively simple,” the researchers note in a working paper.
Researchers used an input of $16.2 million, the estimated long-run annual full-capacity operating cost of University Hospital. Using the model, the team found that a $16.2 million investment in the hospital spills over into other sectors of the economy, resulting in an impact of $29.4 million in the broader Haitian economy. To learn more and see a graphic illustration of this model, click here.
Four years after the earthquake, Partners In Health is grateful to the many supporters and partners who helped make University Hospital a reality for the people we serve, and we look forward to making an even greater impact through our sustained commitment to Haiti in the years to come.
Since opening in March 2013, University Hospital has treated thousands of people who previously had little—or no—access to health care. The facility, built by Partners In Health and Haiti’s Ministry of Health, also serves as a training ground for Haiti’s future clinicians, and is a catalyst for economic growth in the region.
University Hospital provides care for a referral area in which 3.4 million people live, including people in Mirebalais and two surrounding “communes,” or regions.
Since opening, staff members have registered more than 42,000 patients, providing more than 55,000 clinical visits. About 60 percent of patients are from the three regions closest to the hospital, and about the same proportion are women, according to data from the hospital’s electronic medical record system.
“The quality of care patients are receiving is speaking for itself, and the word is getting out,” said Marc Julmisse, University Hospital chief nursing officer, who is Haitian-American. "Our staff is doing an amazing job, and it goes to show—from outpatient services to inpatient care to the emergency room—that Haiti needs a hospital like this.”
Clinicians see more than 700 patients on a typical day.
The hospital employs about 700 people, including about 300 nursing staff and 50 doctors. Seventy percent of its employees are from the Central Plateau.
The hospital has an emergency department, state-of-the-art operating rooms, and a specially designed electronic medical record system. A system of 1,800 solar panels produces most of the facility’s energy needs. To read more about University Hospital’s solar energy system, click here.
Demand for services has grown as referrals from other facilities increased and word spread about free specialty care at University Hospital that was unavailable elsewhere in Haiti. For example, analyses of where surgery patients live show that people travel from all over Haiti to receive surgical care at the hospital.
Since the maternity wards opened, clinicians have delivered more than 800 babies, about 25 percent of which were born through cesarean sections—a rate that reflects the hospital’s role as a referral center for pregnancies with expected complications.
Since March, the following services have opened at University Hospital:
On April 28, Dr. Paul Farmer stood before a microphone in a large conference room in Haiti's University Hospital.
Several days before, bomb blasts at the marathon in Boston, Massachusetts, had killed three people, but not a single person who made it to a hospital died. In that grim emergency, teaching hospitals made a difference, Farmer told the crowd.
“I love working at a great Boston teaching hospital, Brigham and Women’s. I love being able to train the next generation of physicians and nurses. And I want Haiti to have something like it, too,” Farmer said.
This month, University Hospital in Mirebalais, Haiti, took a significant step toward becoming the teaching hospital envisioned after Haiti’s 2010 earthquake, which devastated the country’s already-fragile medical infrastructure. On Oct. 1, the hospital’s first medical residents—all young Haitian doctors—began hands-on training in pediatrics, general surgery, and internal medicine.
The application process was intensive and merit-based: 238 people applied and took an entrance exam. Of those, 45 were interviewed, and 14 were selected. Class members hail from all over Haiti. Some studied at Haiti’s state medical school or private schools in Port-au-Prince; others went to the Dominican Republic. Some just graduated from medical school and completed their social service year; others have been practicing for a few years. By coincidence, the class is evenly split between men and women.
Dr. Jean-Louis Willy Fils, 29, from the northern city of Cap-Haïtien, has wanted to be a doctor for as long as he can remember. He describes surgery as his “true vocation,” so to be selected for a University Hospital residency was more than he hoped for.
“One year ago, I couldn't have even imagined learning surgery in a hospital with an international standard of quality, for the good reason that such a hospital didn't exist in the country yet,” Fils said. “That's the proof that great things can be done in Haiti.”
Over the next several years, these 14 doctors will receive instruction from Haitian and foreign physicians—some of whom are faculty at the same teaching hospital where Farmer trained and now teaches. The curriculum for their training was developed through special working groups and designed to follow the Accreditation Council for Graduate Medical Education International’s (ACGME-I) standards.
After completing orientation this month, residents will begin caring for patients as well as rotating in departments such as emergency medicine, TB/HIV clinic, and oncology. Each day, they will spend an hour in special education sessions for residents, and once or twice per week they will be on call throughout the night. They will also conduct research to improve the quality of care. The ACGME-I guidelines require they work no more than 80 hours a week, but they’ll probably come close.
"The residency program at University Hospital represents the most serious attempt, to my knowledge and during my lifetime, to systematically create a critical mass of Haitian physician specialists that will have the opportunity to be fully useful to all Haitians," said Dr. Pierre Paul, PIH senior advisor. He added that he and his physician colleagues have traditionally questioned the poor outcomes of Haiti's health sector, but now feel questioned themselves about their responsibility to improve health care in Haiti. "University Hospital and its new residency program stand as formidable evidence of the efforts that young Haitian health professionals are making to restore, in a sustainable way, hope and dignity in the future of health in Haiti."
As new classes of residents begin each fall, the number of physician trainees will double and triple. And the programs will expand to include other health professionals, such as nurse anesthetists and other nurse specialists, as well as more medical specialties—such as emergency medicine—which would be the first such training program in the country.
In addition to hands-on training, the curriculum includes lessons on social medicine and the root causes of disease, such as poverty, which have been part of PIH’s work since its early days in Haiti. The programs are designed to train and retain a new generation of doctors to the poor who work outside of Port-au-Prince, the traditional mecca for medical training.
“We envision a workforce of doctors, nurses, and other health professionals who are driven by medical excellence and committed to high-quality care for all Haitians,” said Michelle Morse, PIH deputy chief medical officer for Haiti. “The start of these residencies brings Haiti one step closer to this vision.”
The American Medical Association describes the training for doctors in the United States as “lengthy.”
Four years of college. Four years at medical school. Up to seven years in a residency program and three years in a fellowship for specialists, who make up 95 percent of American doctors.
Add it up, and many doctors have had more than a decade of medical training. Much of it takes place through hands-on coaching from senior physicians in teaching hospitals with all the latest diagnostics and treatments.
In Haiti, one reason for needless sickness and death is the lack of trained professionals to provide health care. There are only 25 physicians per 100,000 Haitians. The United States has more than tenfold that number: 280 doctors for every 100,000 Americans.
In Haiti, half of doctors are generalists who have completed medical school and a social service year but no specialty training. Each year, about 450 graduating doctors compete for only about 150 residency positions.
Those residencies allow Haitian doctors to become specialists in fields such as internal medicine and pediatrics, but even those additional years of training are wanting. Most residencies are based in hospitals that are ill-equipped and under-staffed, with limited supervision by experienced doctors. Attending physicians are underpaid, leading many to spend their time in private practice, instead of teaching physician trainees.
PIH conducted a survey of Haitian residency programs to better understand the country's medical education needs. The survey found that 55 percent of residents don’t have Internet access at the hospitals where they work, and 80 percent of the programs do not have an exit exam for residents.
“These residencies are operating in hospitals that are severely short on resources, from staff to equipment,” Morse said. “University Hospital has electronic medical records, an emergency department, a CT scanner—it allows us to have a whole new level of quality care and training at a hospital with the appropriate resources.”
Double brain drain
The lack of opportunities leads many young Haitian doctors to seek training and employment in other countries, causing a brain drain in the health workforce. A staggering 80 percent of all physicians trained in Haiti leave within five years of graduation to practice abroad. Of the doctors who stay in Haiti, most practice in Port-au-Prince, which makes it difficult for rural people to access care. The medical education programs at University Hospital aim to slow or even reverse that double brain drain—from rural to Port-au-Prince or abroad—by encouraging talented young doctors to train in Haiti and stay there to practice medicine.
Dr. Ketly Altenor, 27, hopes to return to St. Marc, Haiti, to practice medicine. Growing up there, Altenor lost her father at 12 years old, and her mother supported the family as a street vendor. Despite her family’s poverty, Altenor excelled in school and earned a competitive spot at the state medical school. She graduated with the support of a scholarship from the nonprofit Haitian Education and Leadership Program, which provided housing, a stipend, and mentorship. She was accepted into the pediatrics residency at University Hospital after graduating from medical school.
“After my training I intend to return to work in my hometown, where there aren’t enough pediatricians,” Altenor said. “I will try to extend pediatric care to remote areas of the Artibonite region. I want to work in social medicine and really help people.”
Though University Hospital’s medical residencies are just starting, other training activities have occurred since the hospital opened. Since Farmer delivered his talk, or “grand rounds,” to inaugurate medical education at University Hospital, staff have participated in daily continuing education sessions to improve care, from training on using ultrasound to sessions to help faculty become better teachers.
As Farmer said, “University Hospital was built to be a teaching hospital because the hypothesis, here, is that the quality of medical care will be improved whenever training and research—the ‘feedback loops’ that allow us to learn—occur in tandem with compassionate care.”
This essay from PIH's Stephanie Garry originally apperared in the Tampa Bay Times.
The gleaming white hospital appears out of nowhere in the bustle of this impoverished city in the Central Plateau of Haiti.
It seems even more out of place when you consider what's inside: 300 beds — more than All Children's Hospital in St. Petersburg. Six operating rooms. A neonatal intensive care unit. A CT scanner, the only one available to the public in Haiti. Most important, patients. More than 10,000 have seen clinicians since the hospital opened this spring.
It's one of the few visible signs of progress since the 2010 earthquake leveled Port-au-Prince.
More than half of American households donated after the earthquake to help a poor country with bad luck. But for the most part, the grand plans of building back better have not materialized. The 1.5 million people living in tents after the earthquake are fewer, but many were forcibly evicted. A garment factory and a luxury hotel, both underwritten by aid, opened with fanfare. These milestones hardly amount to a resounding victory for the people of Haiti.
Against this disappointing effort, University Hospital stands out as a testament to how much can be accomplished in Haiti. It can teach us how to achieve rebuilding and development with effective aid that endures, and better deliver on the generosity of the American people.
The popular narrative would tell you the recovery fell short because Haiti is difficult, unstable, dangerous and corrupt. Just a few days after the quake, New York Times columnist David Brooks blamed Haiti's trouble on "progress-resistant cultural influences." It's a facile explanation of a complex place, but a lot of people found it convincing.
My experience has led me to believe something else. I lived in Port-au-Prince for nine months and now work in Boston at Partners In Health, the global health nonprofit that built L'hopital Universitaire de Mirebalais under the guidance of Brooksville native Dr. Paul Farmer. In my view, the problem lay not with the Haitians but the aid industry that came to their rescue.
The earthquake recovery was largely composed of nonprofit organizations that are more eager to please donors than the people they purport to serve. Too often, they pay lip service to working with communities while largely ignoring them in designing their programs. Many of the so-called experts on alleviating poverty had little experience in Haiti and no plans to stay long term.
I saw this firsthand during my time working for Fonkoze, an exceptional Haitian microfinance bank serving the rural poor. I attended an aid organization's workshop to create a website to help poor, rural people improve their lives with information — people who are mostly illiterate and lack access to electricity, computers and the Internet. I heard an American aid worker complaining that the luxury housing provided by her nonprofit employer didn't have enough style.
It seemed like so much money went to Haiti after the earthquake, but less than 1 percent of the $2.4 billion in immediate earthquake relief went directly to the government of Haiti.
In the longer-term recovery effort, the U.S. development agency USAID spent $1.15 billion, more than half going to American firms in the D.C. area and less than 1 percent to Haitian firms and nonprofits, according to the Center for Economic and Policy Research.
Haitians weren't in charge of the projects, but they shoulder the blame for failures. Their country is characterized as a black hole for aid.
If national systems are weak, diverting money and projects away from the government only worsens the problem. It isn't easy to work with a government that is chronically short of resources, but it's the only way to strengthen the public sector to ensure the rights of its citizens.
There are many problems with the way aid works, but at the root of it is how we view the poor and disadvantaged, and more broadly, any group of people we seek to serve.
Beneath the complexity of actors and projects, the core of the problem is a misinterpretation of poverty.
As well intentioned as they can be, both aid and charity take the subtle view that there is something inherently wrong with the people being served. Otherwise, the argument goes, why would they need our help?
In reality, disadvantaged people are systematically deprived of the basic rights that would enable them to rise out of poverty — food, clean water, decent sanitation, housing, jobs, health care and education. The ambitions of aid are often too small, focusing on modest, short-term interventions instead of the long, painstaking work of building systems to ensure rights, in partnership with the government and local institutions.
In Haiti, this denial of rights is not innocent, but the result of centuries of international interference and oppression. A couple of recent examples: Just a decade ago, on claims that Haiti's government was interfering with the elections of eight senators, the United States blocked international loans to improve water and sanitation systems. In 2010, less than a year after the earthquake, a U.N. peacekeeping force inadvertently brought an epidemic of cholera to Haiti by dumping its sewage in a major river system. Cholera has since killed more than 8,000 people and sickened more than one in 20 Haitians.
Instead of fixating on personal failings of the people of Haiti, we should work with them to build systems that ensure access to education, health care and food. The rights-based approach guides us to imagine doing more than offering castoff goods and services — the XXL T-shirts or the expired medicines or the spring break service trips. Pragmatically, a human rights approach works better because it confronts difficult, interconnected problems with significant solutions, not small, cheap interventions like chlorine for purifying drinking water or transitional shelters that, by themselves, offer little hope of lasting change.
Partners In Health, along with its sister organization, Zanmi Lasante, works to improve the quality of care in the public health system, collaborating with Haitian communities and the government to train health care workers, develop new services and improve rundown facilities, including building top-quality infrastructure.
In the case of University Hospital, the Haitian government identified the need for a national teaching hospital after the earthquake, and Partners In Health/Zamni Lasante worked alongside the Haitian Ministry of Health to design and construct the $17 million facility, with the help of many in-kind donations. Through a public-private partnership, the government and Partners In Health/Zamni Lasante will contribute to operating costs, and management of the hospital will gradually transition to the government over the next 10 years.
Partners In Health builds open-ended partnerships that don't end when the earthquake donations dry up, offering a greater chance at slow, lasting progress on entrenched problems of poverty and inequality. We call this "accompaniment," to convey a shared journey.
Developing partnerships based on empathy and pragmatic solidarity — not pity or even sympathy — is the essential first step in serving people in need.
Early on May 23, nurses and doctors dressed in blue scrubs and prepared for University Hospital's first surgical case. The instruments were sterilized, positive air pressure minimized the risk of infection, and Haitian nurses provided anesthesia. Dozens of partners — corporations, generous donors of time and money, medical professionals, and Mirebalais housekeepers — had worked together to make this day a reality. It wouldn't have been possible without years of work to strengthen the health system in the Central Plateau, so that patients could be connected to care from their homes to the hospital.
The patient was a 60-year-old Haitian woman and mother of four, diagnosed with breast cancer by a Haitian doctor. A Haitian surgeon from Mirebalais and his American counterpart worked side by side in a fully equipped operating room to perform the mastectomy. As with all work at University Hospital, procedures like this serve two purposes — first, and most important, to heal the patient with a standard of care that compares to a top-quality teaching hospital anywhere else in the world, and second, to train Haitian medical professionals to provide that kind of care. With this operation, the Haitian woman has received new hope and a greater chance of living longer with a better quality of life.
In the United States, there would be no question that a woman with breast cancer receives care — including a mastectomy — to save her life, and health facilities provide it routinely. Yet development experts debate whether this care is worth the cost in low-income countries. Should we spend the money on and invest the time in systems, with the necessary infrastructure, equipment, supply chains and drugs, to treat complex cases like cancer?
The patients in need of care and their doctors always say yes. Our role is to support them.
University Hospital was built in less than three years, long enough for the majority of earthquake responders to come and go. It will remain, serving the people of Haiti long into the future, as a testament to how much can be accomplished when you view the people you seek to help as equal partners.
Stephanie Garry is a former Tampa Bay Times staff writer who served in the Peace Corps in the Dominican Republic from 2009 to 2011. In 2011, she worked for Fonkoze in Port-au-Prince, Haiti, before joining the Partners In Health staff in Boston. Views are her own.
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