The pediatric hospital I worked at was built out of the old residence compound for the Mexican Ambassador. This is not an absurd transition as many of the hospitals, schools, and orphanages in Port Au Prince were transformed from some other structure previously used for a completely different purpose or by a different political regime. Some hospitals were staffed by local physicians, some had residents who were a part of the medical education system, some by rotating international volunteers, and few almost entirely by nurses and community healthcare workers. I visited a clinic with electronic medical records that disposed of their used needles by dropping them in a bin outside the door. Haiti’s healthcare system, if any, was disorganized and inconsistent.

The potential of creating infrastructure from scratch is one that can be appreciated by all (especially those of us in the US). The goal should no longer be to leave the country in the state it was before the earthquake; the complete destruction of the infrastructure has forced the solution of rebuilding, as opposed to fixing. And this distinction is important when considering the possibility of creating something better than was in prior existence. Haiti has the unique opportunity of building a system from the ground up. Finally it is Haiti that will benefit from the trial and error of the rest of the world, as it takes from our successes and failures and crafts a system from these lessons. Supported by experts around the world as well as millions of dollars in resources, I can’t wait to see what is sculpted from this struggling, destroyed, blank system.

I used to look at this picture of a Haitian boy and think about what he’s doing. I met him while working at HUEH hospital, in Port Au Prince when I was visiting last November. He lives in a metal crib with 4 other disabled, abandoned children in a room that smells like urine and is filled with an awkward combination of moans and shrieks. There are two women who sit in chairs outside the room and twice a day they feed him a mushed brown rice dish and once a day they change his diaper. He is one of thousands of children in Haiti either living on the street, or confined to a small room, with hardly anyone to look after him.

This was his life before the earthquake. I have no idea what has happened to him although of the many scenarios I’ve envisioned none are optimistic. I’ve heard mixed reports, the most respectable from the head of pediatrics who emailed that the call rooms where the physicians sleep collapsed; underneath which is the room where this boy lived. I heard that they have to date, 2 weeks later, still failed to locate over 50% of the hospital staff and even more are still not coming to work. I don’t know if those two women, the same two that were there outside the room the year before when I visited, survived the quake, and if they did, whether they were going to work. And if they weren’t going to work, which seemed more probably to me, who was feeding this little boy of mine?

Haitian healthcare was resource poor, unorganized, and in great demand- before the quake. As the poorest country in our Hemisphere, Western medicine and resources have been slow to make their way to this half of Hispaniola. Is this because of the political unrest, fluctuating safety and security, or general lack of awareness? Post-quake, there is no longer a lack of awareness. What does a healthcare system look like when it has gone from bad to worse? How do you pull out of such a mess, and do you aim for what things were like before the disaster or seize the opportunity to aim higher?

Partners in Health, a nonprofit that has been working in Haiti for years, sent out an email to the medical community shortly after the quake asking for orthopedic and trauma surgeons.  Most other organizations followed similar guidelines, including a team from Stanford composed entirely of ER doctors and nurses.  This is because the type of medicine currently being practiced in Haiti is unlike any medicine most of us have ever seen; disaster medicine.

Grace Children’s hospital, a small pediatric hospital run by ICC international, has transformed their front lawn by hanging sheets between the trees to create an outdoor clinic. Physicians, mostly international volunteers, long ago ran out of gloves and antiseptic and are using their bare hands and street vodka to clean materials. Rationing limited pain medications and coming up with creative ways to set broken bones have taken a toll on the physician’s creativity. I saw a Black & Decker drill, normally used to hang paintings now being used to connect two bone pieces back together. I was impressed when I read a report about an ER physician inserting a central line (catheter into the large vein in the neck) into a patient laying on a slab of concrete under the baking sun. Physicians are carrying patients on their shoulders hundreds of feet to open areas being used as operating rooms.

Disaster medicine is being practiced without everything we consider to define the profession; no gloves, white coats, x-ray, or even medications. Everything that is, except for the doctor.

As you’ve been reading in my previous blogs, seeing healthcare in a developing country has affected how I view the U.S. reform. I’m frustrated by its complexity, I’m confused by our waste, I’m annoyed by the politics, and I’m concerned for those without coverage.

Why is it so complex? It’s a known fact that incentives impact the way in which things get done. We should have alignment and agreement from patient, to provider, to payer, and back, so that everyone’s goals, including financial, involve efficient, quality care. This is a must.

According to the World Health Organization (2005), the US government spends more on healthcare per capita than almost any other country. Even more than countries entirely funded by the government. And on top of that, the average American is chipping in about $3,600 a year. This is wasteful. We can do better. Look at end of life care, look at places like McAllen Texas which spends almost twice the national average per capita, gather up our economists, and strategize to bend the cost curve.

One, the AMA rejects the public option. Two, Obama administration offers to retract the 20% pay cut to physicians promised by Medicare. Three, the AMA endorses Obama’s healthcare bill. This is politics, and this must be controlled before we can see anything progressive come out of Washington.

My professor told me about two patients of his who needed transplants, one from Illinois where Medicare paid for the procedure, and one from Indiana where Medicare didn’t; the former lived, the latter never got his transplant. This is not America, this is not acceptable. In assuring equal pursuit of happiness, we need to guarantee healthcare for all living within our borders.

I was once told, when trying to solve a problem, there’s no need to reinvent the wheel. Why aren’t Americans looking outside our borders at our more efficient, even healthier, counterparts?  After spending just one week observing healthcare in Haiti, I realized that even from a struggling, resource deprived country, we have a lot to learn.

Traveling to a 3rd world country is an eye opening experience. Rarely in the US do you see the clinical manifestations of disease such as Kaposi Sarcoma, or corneal scaring with Vit A deficiency. However, the educational value needs to be shared by both visiting and local physicians. In addition to equipment, physical resources, and technology which are hard to come by in terms of donations, what else can be given to improve the capabilities of local physicians? This is a difficult issue at the core of the debate surrounding medical tourism.

The power of research and evidence based medicine has lead to countless improvements in healthcare in the US. A US physician from Philadelphia collected data on childhood mortality in the ER in Port Au Prince and presented her findings back to the team of local residents. They were fascinated by her findings on what was and wasn’t working. The Haitian physicians were not trained in statistics or evidence based medicine, and the hospital was far from being able to provide additional staff for this purpose. This US physician used her training, time, and expertise to provide a valuable and lasting service to the hospital. She also gave examples of ways other hospitals in various locations around the world had approached a similar problem. Providing analyzed data back to the local physicians gave them the big picture ammunition they needed to be able to critically evaluate and improve their own practices in an efficient, and most importantly- sustainable, and resource possible, fashion.

As I saw the discussion going on amongst the local physicians after being given statistics on the effectiveness of their care, I thought about the potential a massive, nationwide database could have.  Our President contends that one of the benefits of a largely utilized Public Option would be the creation of a comprehensive database, similar to the information gathered by Medicare and Medicaid. I thought about this cited benefit and pondered the limits, if any, such a data bank could have on the evaluation of healthcare in my own country.

I shadowed an OB/GYN physician at a ‘family planning’ clinic financially supported by an international NGO with religious roots. He wore a tie, a nice watch, and was educated in the country. Patients were triaged by the nurse, this included weight and information gathering about family history, last menstrual period, etc., and then seen by the doctor who re-checked all of the information handed him. One of his patients was a 15 year old who came in twice a week for him to apply medication to treat her STI (STI is currently the more accepted term for sexually transmitted infections). He didn’t trust that she would remember, have clean application materials, or even a private location to apply herself.  The rest of his patients came for a free pre-natal visit during which he performed a breast examination, pap smear, and gave financial planning strategies to save enough money for a taxi when the time came to deliver. When patients told him that a sister or friend was going to get them to the hospital, he continued to question for exact details of this plan.

We found a breast mass in a 32 year old 4 months pregnant. He told me uterine cancer was a big problem amongst his patients and he looked at me frustrated when a patient asked what a pap smear was. He told me that the only time he sees most women is for this prenatal visit, and he therefore feels, “not doing a pap smear or breast examination is a missed opportunity to catch these things.”

I left out a detail of his prenatal visits that I found fascinating; he introduced the topic by asking how many children the woman intended to have and then cut to the chase: “And what type of birth control will you be using to prevent future pregnancies?” I pictured a couple in the US going to their first prenatal visit together and getting a lecture on birth control. “Doctors in Haiti are not just doctors, they are public health workers,” he told me between patients. I was struck by his energy and compassion to work on the big picture while sweating away in his tiny exam room. I thought about what a great physician he was and what a role model he had been for me. This made me think of the distinct fields public health and medicine have become, unfortunate when considering their emergence as one and similar intentions. I thought about Tuesdays when I leave the School of Medicine building where I have Biochem and Pharmacology, and walk across the street to the School of Public Health to take Introduction to Policy and Epidemiology for my masters. It goes without saying that the US has innumerous resources and technology to offer medicine in 3rd world countries. Physicians seeing themselves as public health workers is an important lesson we can learn from those practicing in less privileged environments.

I was told by one of the local residents that pediatric death due to septic shock is a huge problem. Children coming into the ER in Port Au Prince are carried on foot by their parents, assessed by the physician, and then the family (in the case of sepsis) is told that rehydration (a bag of saline) is needed. The family then gathers the funds to go to the pharmacy across the street, buy the saline (hopefully only one bag is needed), and return to the hospital in time for the patient to be treated.  The bag costs the equivalent of 15 US dollars, think about this in light of the fact that dinner at a glamorous Haitian restaurant in Peytonville (the most affluent neighborhood) costs 5 US dollars a person. Many families can’t afford to purchase the rehydration solution necessary to save their child’s life. In other words, the payment scheme in place in this hospital leads to the death of 3-5 children a week.

None of the patients treated at this hospital have insurance. I wondered, given this blank slate, what payment scheme I would choose to put in place. Fee-for-service payment methods pays the physician based on the number of procedures or interactions had with the patient. I imagine this would be difficult to measure in a country where procedures and services are not distinct like an EKG. The down fall with this plan is that US physicians have been found to overprescribe, although I doubt that Haitian physicians would be found to recommend in excess because of the overwhelming shortness of time and resources present.

What about paying the physician based on the number of patients they have, referred to as capitation? In the US this method is appreciated because it sets up a financial incentive for the physician to keep his/her patients healthy because he/she is paid regardless if the patient is treated (and a healthy patient requires less work for the physician). Would patient outcome in Haiti benefit from their physicians having a financial incentive to keep them healthy? I don’t think this is necessary.

Currently, Haitian physicians are salaried. I found them intelligent, empathetic, realistic and hard working.  I heard about a few residents pooling their money the night before I came to purchase a bag of saline for a particular patient they felt invested in.  These physicians worked long hours, traveled through dangerous neighborhoods to get to work, and battled the enormous frustration of trying to practice medicine in an environment defined by lack of resources. The way in which they were paid seemed irrelevant, and my thoughts on how to improve care in Haiti were focused solely on how to improve care for the patient, not on strategies to motivate the good intentions of physicians.

The Labor and delivery room in the main government hospital in downtown Port Au Prince is a single room with 25 or so metal beds placed 5 feet apart all facing center. There are 2″ thick pads on the bed that are wiped off with a towel in between patients. Nurses, six of them, stand in the middle of the room chatting and wait until they determine a woman’s cries to be indicative of impending birth, at which point they rush over with the sole OB physician, and deliver the baby. The baby is suctioned and toweled off by the nurses and handed back to the mother who will go home 6 hours later.

Pediatricians are not present during the delivery, however if a baby comes out sick, or still, the nurse runs out of the room, out of the clinic, through the front gate, down to the end of the street and into the pediatric clinic where she must roam around looking for a physician who is able to leave his or her current patient. The summoned physician then briskly walks back along the nurse’s path to the OB clinic to assess the situation. There is no vacuum suction, no oximeters, no oxygen, no x-ray, no ultrasound and no specialists.

Outside the delivery room is a long line of women sitting in chairs as though waiting to use the restroom, except they are waiting to get in to deliver. According to one nurse, many women deliver out in the waiting area.

Saving you further descriptive details of the birthing process in this common room, I want to say that privacy was not an element of the patient’s experience. And more importantly, no one seemed to care. I thought about the ways in which we could improve the delivery process for the women here, would providing them more privacy serve any benefit? Of the many ideas I had to improve their care (i.e. more training for the MD’s, availability of specialists, supplies, etc. etc.), privacy was not a consideration. Apparent, for example in the debate on the security of online PHRs, patient confidentiality and improving privacy is a major focus in the US healthcare system. Why? Do we have such an excess of resources to analyze, change, and implement that we go searching for elements of care to improve?

I returned to a country consumed with the debate on our healthcare system, and I found myself annoyed with its complexity. As I returned to my public health courses, and I learned more and more about our system, I knew that my opinions and involvement were altered because of my experience with a simpler, less convoluted system.

“Be the change you want to see in the world”-Gandhi.

For my best friend, I’ll be confident in my ability to make decisions. For my sister, I’ll be easy-going. For my mom, I’ll involve myself in more than just my work. For my dad, I’ll eat healthier and invest in my longevity. And for myself, I’ll accept if none of those people catch on.

I wish I had not discussed other applicants’ medical success and failures (actually no one admits failures) before walking into my interview. Hearing from the applicant next to me about her masters in biochemistry, and her 11 other interviews she’d had by November (many from schools I had not yet heard from) was slightly counterproductive to my nerves, and confidence, right before walking into an interview. Avoid asking others what they are doing and stick to things like ‘What undergrad did you go to? Did you have fun in Chicago? What do you know about this school?’ It is important to interact with your fellow applicants, comparing resumes is not the best idea, especially pre-interview.

I was so happy I had brought a toothbrush and toothpaste in my bag. One interview we were given financial aid information, ate sandwiches and Doritos, then interviewed. After lunch I took a few minutes in the bathroom–oh yea, always take a breather by going to the bathroom, wash your hands, whatever-and I brushed my teeth. Dorky? OCD?  Don’t care, I walked into my interview feeling refreshed and confident as I sat 3 feet away, face to face with my interviewer.

And now for the painful part. I had taken three steps out of my first interview before I thought “What was I thinking??!” The goal of an interview is to sell yourself.  I had given an answer to all of the questions I was asked, but I did not sell myself. Example:

I was asked, “What clubs were you a part of during your undergraduate years?”

I answered, “French Club.”

This was the extent to which we discussed my undergraduate experience. By asking what clubs I was a part of, this was the interviewer’s attempt to gain insight into what I did other than study.  This was my chance to talk about flute ensemble, community day, incoming student recruitment coordination, teaching swim lessons to disabled children, or any of the other interesting things I took part in during undergrad. Instead, I heard the word “club” and my brain immediately went into a word search for the four consecutive letters C-L-U-B listed in the title of my activities. Oops.

And another oops. After discussing a summer internship I did 5 years ago working as a medical assistant…

I was asked, “Tell me about your most meaningful experience working with patients.”

I responded, “Working as a medical assistant? Well…”

And I launched into a discussion of my interaction with an elderly patient I had when I was 19 and then the interview was over. For the past two years, I have worked as a patient advocate and resolution negotiator in the emergency room. I have been with children watching their parents die, I have waded through blood on the floor of the trauma room to get a cell phone and contact family members, and I have had 4 phones up to my ear trying to get a legal copy of a DNR as I watched doctors pound away on the patient’s chest.  Sell yourself. When asked about my most meaningful experience, or any other question for that matter, I wish I would have had less fear about directly responding to the specific question, and have been more proactive about selling myself.

Primary application. Secondary application. Interview.  I traveled 3 days and 3,000 miles across the country to talk about French club and a summer internship. Lesson learned.