In Haiti, a Lesson for U.S. Health Care

By JAMES WILENTZ
Published: July 28, 2010
IN February, a month after Haiti’s earthquake, I went down to Port-au-Prince as part of a team that was helping to reactivate cardiac care in the city’s public hospital. For several months since, I have observed how the earthquake and its aftermath profoundly changed Haiti’s health care system. Over that time, I have come to the unorthodox conclusion that Haiti’s tragic experience may show us a way to improve health care in the United States.
Let me explain. The sudden availability in Haiti of free high-quality care from foreign doctors put enormous competitive pressure on the private local doctors, who had already been working under difficult conditions. Watching this situation unfold, I found myself wondering if the same would happen to private medical services back in the United States were our government to suddenly provide high-quality, low-cost health care.
Haiti, with the worst health care record in the Western Hemisphere — the infant mortality rate is nine times that of the United States and the maternal mortality rate is 50 times as high — was ill prepared to help disaster victims. For the public hospital in Port-au-Prince, earthquake damage only made things worse. Into this vacuum surged hundreds of international doctors and nongovernmental health care organizations.
In the beginning, of course, those with immediate injuries were treated first. But even after the earthquake victims had been taken care of, lines more than a quarter-mile long still formed at the hospital entrance. There were mothers carrying babies with swollen bellies, prematurely old men and women with waterlogged legs and labored breathing, people with painful sores and lots of people coughing. These were Haitians who’d had no access to medical care in a long time and who suddenly saw hope in a hospital full of foreign doctors eager to help at no charge.
This humanitarian aid came with a downside though: it caused many of Haiti’s local private clinics to lose business. One such clinic is Michel Théard’s cardiac practice, near the public hospital where I worked. Before the earthquake and during the immediate aftermath, Dr. Théard did echocardiograms (ultrasound images of the beating heart) for cardiac patients, because the public hospital lacks the equipment to do them. His ultrasound pictures, and those done by other private Haitian cardiologists, often at charity rates, enabled us to diagnose many conditions for patients in the public hospital.
But because Dr. Théard, and the private hospital with which he is affiliated, cannot compete with free foreign doctors, there is a danger that he will no longer be able to stay in business and provide echocardiograms for the poor.
There are many other services that only private doctors provide in Haiti, because the public hospitals are so poorly financed. The rudimentary intensive care unit at the public hospital has no heart monitors, oxygen sensors or any other kind of modern medical equipment. The only thing “intensive” about the I.C.U. is that a health care worker (doctor, nurse or nurse-anesthetist) is present at all times. A CT scanner donated to the hospital in the early ’90s lies rusting outside one of the buildings, sad evidence of the public medical system’s failure to provide adequate care.
Patients who can afford it get specialized procedures like CT scans and echocardiograms at private clinics and then return to the public hospitals for free care. This is also the case for many medicines: family members buy them at a pharmacy and bring them back to be kept under the patient’s hospital pillow for dispensing at the prescribed times.
Perversely, by shoring up the capacity of the normally dysfunctional public health system during this crisis, the foreign doctors may be further damaging Haiti’s fragile medical sector. Once they leave, who will be left with the will and the capital to adequately care for Haitians?

James Wilentz is a cardiologist at the Lenox Hill Heart and Vascular Institute.
http://www.nytimes.com/2010/07/29/opinion/29wilentz.html?_r=1&scp=4&sq=Haiti&st=cse