(Washington Post, March 25, 2010)
Steady supply of medical services begins to pressure Haiti's doctors
By Lois Romano
Jerry and Marlon Bitar are prominent Haitian surgeons, identical twins who have done everything together for all of their 48 years. They both studied medicine in France, returned to Haiti in 2000 to take over a clinic serving low-income patients, and built a separate private practice that has given them national prominence and paid the bills.
In the weeks following the deadly Jan. 12 earthquake, they worked 18-hour days side by side, performing 900 surgeries and amputations free of charge between both of them. And now, their lives are defined by the same split reality: "before the earthquake" and "after the earthquake."
Sitting in their cramped office, the brothers tell the story of most Haitian medical providers and hospitals. Since the earthquake, Haiti has been awash with doctors from all over the world providing the kind of top-notch care rarely experienced in this chronically poor country. It has been a gift of epic proportions, the Bitars say, in a place burdened with disorganized health care, and high rates of HIV and tuberculosis.
But as the immediate crisis starts to wane, more and more patients with maladies unrelated to the earthquake are turning to international health-care teams led by the World Health Organization, raising concerns about Haiti's ability to care for its own once the relief teams pull out and need for rehabilitation and long-term care grows.
The Bitars ask what appears to be a simple question: How can the country's medical structure be rebuilt when hundreds of humanitarian teams are still providing health care for free? The surgeons say they have no income -- not from the poor and not from their private practice. For one, 700,000 people are now homeless with no access to funds. For another, the hospitals, the Bitars and others say, are finding it hard to compete with the visitors. With no end in sight, some of the nation's doctors have already left, and others are considering leaving.
"We have not been able to make payroll for two months," Jerry Bitar said.
Marlon added: "I am very worried that many of our good doctors will leave. The humanitarian hospitals, they don't ask for any money. Yesterday, I went to one and saw two of my private-paying patients getting treatment there."
Indisputably, international organizations are carrying the Haitian health-care system today -- and will continue into the indefinite future. Many Haitian health-care providers were among the 230,000 killed in the earthquake, and others have not shown up for work, dealing with their own losses. The nursing school at the University Hospital collapsed during exams and killed essentially an entire first-year class of nursing students.
"It is a very difficult situation," said Thomas D. Kirsch, a professor at the Johns Hopkins medical school and an expert in developing-world health issues who was recently in Haiti. "If these organizations pulled out, the system would be worse than ever, and as long as there is free care available, that's where the Haitians will go and the Haitian doctors will have no business. . . . There must be a well-planned transition period to subsidize the Haitian health-care system, have [nongovernmental organizations] work directly with Haitian providers, and to train sufficient providers and nurses to be able to meet the population's needs."
Nyka Alexander, a spokeswoman for the World Heath Organization, said that "the international community working in health will not leave before a system is in place, and this is precisely what we are working on . . . to build an accessible system better than what was here before the earthquake." One part of the plan, she said, was suggested by locals: Build mobile clinics so people don't have to rely on emergency rooms.
"It's going to require strong leadership from the Ministry of Health to develop new policies, training and better pay," said Dana Van Alphen, a doctor handling disaster management in Haiti with the Pan American Health Organization.
The Bitars concede that they are overwhelmed with the new needs thrust upon them, and that current resources are not enough to meet demands.
Down a narrow side street cluttered with rubble and garbage, behind an elegant tall gate, sits the Bitars' oasis of yellow, low-slung buildings, hardly touched by the earthquake. The inside of the Bernard Mevs Clinic tells another story. A dozen tents used as hospital rooms dwarf the courtyard because the patients refused to stay indoors, terrified of another earthquake. Adding to their load, several HIV and AIDS facilities were destroyed, and the doctors faced an additional 500 patients at their door, desperate to keep up with their medication.
The Bitars say they have enough HIV and AIDS medication, donated by the Gheskio Center, and some additional support from Food for the Poor, both nonprofit groups. Beyond that, the brothers say, they have received supplies they don't need -- arthritis medication -- but are low on such basics as sutures.
Many of the patients have been there since the earthquake. A beautiful 13-year-old girl with an amputated leg glumly learns to push herself around in a wheelchair. A 58-year-old man who was pulled from rubble sat for nearly two months before a volunteer physical therapist pushed him to take some small steps this week. A 39-year-old woman whose house collapsed on her and whose neighbors amputated her arm to save her life sits day after day in her tent. When she was brought to the hospital, the doctors amputated her leg as well.
"Our biggest challenge is the next step: Where do these people go to recover?" Marlon Bitar said. "Before the earthquake, we did a surgery, they would leave, go home or stay with a member of their family. Many have lost their homes and families. Now they are our responsibility."
Added Jerry: "Before, they would beg us to go home early after surgery. Now they are crying to stay here." Last week, a group of occupational therapists from the AFYA Foundation in New York arrived unexpectedly. They had airlifted medical supplies and equipment, such as syringes, IV bags, tents, mattresses and blankets. They showed up at the Bitars' clinic and started to train the nurses in physical and occupational therapy.
"I am half a woman," Coreus Aieula told Danielle Butin, an occupational therapist who founded the group and who showed Aieula how to put on a bra with one hand.
"What's the point of saving a life," Butin asked, "if she is going to just sit there for the rest of her life?"