Maternal health: No doctor on site

To write this piece I searched the internet for definitions of ‘access’ and came up with a range of gobbledygook that really says nothing. So I came up with my own simple definition in relation to healthcare for poor and low income women. It has to be free or minimal cost; it has to be located in the neighbourhood; it must be community focused; it has to provide a range of services; it has to have a referral system for specialist care which is also free and or minimal cost; it has to be welcoming and patient orientated; it has to provide primary health care including education on reproductive health, sexual health, maternal health, nutrition and mental health support.

Unfortunately this is an ideal which probably doesn't exist anywhere in the global south with the exception of the two pariahs of global capitalism, Cuba and Venezuela. It isn't that Haiti is exceptional, its most certainly is not. According to a recent Ted X talk quoted in ThoughtLeader, - one newborn baby dies every 10 seconds which is 10,000 babies a day. Every day some 800 women die in pregnancy or giving birth and 10 million a year, suffer from injury and or infection. It’s the normalcy of death at the time of birth for women in Haiti and elsewhere which is most shocking.

Contrary to some media reports Haiti is far from being on the road to recovery. Stories of camps being shut down, people being re-housed, factories opening, and a general air of what the President calls ‘Open for Business’ are greatly exaggerated. Behind the new factories there is a struggle for fair wages, decent accommodation and healthcare. There are struggles for compensation for land seized as people are left destitute without a means to make a living. Cholera remains an emergency whilst the level of healthcare provision decreasing.

No amount of paintwork and covering of the structural and systemic cracks can hide the truth. Over the past few months I have spoken to dozens of people, visited clinics and hospitals, observed patient / doctor visits, witnessed medical crisis and listened to the stories told to me by nurses, community organizers, and patients, most of whom are from the community of Jalouzi and Camp Acra in Delmas 33, as well as Haitian health officials and staff of Medicines Sans Frontier [MSF">

Jalouzi is a hillside neighborhood of about 200,000 people overlooking lower Petion-Ville. Although it was not damaged by the earthquake many of the residents were still affected from being in other areas of the city in those moments. It is accessible from two roads, one at the top and one below. The view from the top is stunning. From here you can see Port-au-Prince [PAP"> looking east to the sea and north to the mountains. You can also see clearly the newly built Clinton Oasis luxury hotel and of course those guests in rooms facing the mountain can see Jalouzi. Jalouzi is one of those cracks which must be painted over and I am told this is being done through the courtesy of one of the newly opened Petion-Ville supermarkets who it is rumoured are painting the hillside houses. The government may not feel it imperative to provide healthcare for the poor but it is prudent to paint their houses, so at least from a distance, everything looks oh so quaint.

The only way to travel through Jalouzi is by foot through a series of alley ways and narrow paths of gravel, stones or the occasional step, and for those like myself who are challenged by gravel and stones on slopes, difficult to negotiate. The promised building of new steps has begun but is proving a slow process. I am with Flaurantin Marie Anise, a community activist and founder of Le Phare [the light"> which works with the most vulnerable women in the neighbourhood. We had driven to the top so she could she could walk me down the hillside neighbourhood. Flaurantin lives midway, where in addition to her home she has a small meeting room and clinic for dispensing over the counter medication. She also runs a kiosk on the lower Jalouzi road and is the Jalouzi coordinator for Fam SOPUDEP an Aksyon [FASA">.

It took us over an hour to walk down the hillside, largely due to my constant stumbles and fear of breaking a limb or two and needing rest periods from the associated anxiety. Once down we had another 20 minutes walk to the FASA shop where we relaxed with sodas and warm bread.

There are no clinics in Jalouzi and the nearest truly free hospitals, are between 1 and 2 hours away by public transport and foot. The nearest emergency maternity center is the Centre de Référence en Urgences Obstétricales (CRUO) run by MSF [1]. Most babies in Jalouzi are delivered either by the 150 matrons living in the neighbourhood or women like Flaurantin who have no formal training but are regularly called to help with childbirth and other medical emergencies. As we sat and discussed the difficulties of negotiating the hillside in a medical emergency we heard a commotion outside on the street and seconds later two men rushed into the shop carrying a pregnant woman. Flaurantin immediately ushered them to the rear and brought out a stretcher for the woman who looked in her 50s and appeared weak and confused. She made no sound as if her body did not have the energy even to cry out. Her breasts, which should have been heavy, were soft and clung to her chest. A large sheet was found to provide some privacy as Flaurantin eased on rubber gloves and proceeded to examine her. She determined she had a few hours to go so it was decided to try to get her to the MSF CRUO hospital in Delmas 33. This required her being carried up a steep path, then across Petion-Ville into a tap tap taxi for a journey of about 40 minutes, then a further tap tap before reaching the MSF hospital. She was lucky, her child, a boy was delivered safely and the two are now back home.

Everyone I have spoken to in PAP on health issues always mentions and speaks highly of MSF so I decided to visit the CRUO at Delmas 33 which opened two years ago. The hospital, a free emergency referral center for the whole of PAP, admits pregnant women who are ‘gravely ill’. The MSF maternity project has a six-year history which began in at the Maternity Judan Hospital in Delmas 18 and was open to any pregnant woman who was sick. This was the first truly free hospital in PAP. Although public hospitals are designated as free, in reality patients have to pay for medication, drips, sometimes even gloves and consultation.

Because the MSF was free, women from all over the city were attending the clinics and eventually they had to introduce specific criteria for admissions. They also moved to a new larger location near the airport which was called ‘Lopital Solidarity ‘. The earthquake destroyed the hospital and two years ago they moved to their present location where they only receive pregnant women who are in ill with complications like eclampsia which is extremely common.

The nurses and women in Jalouzi had explained that eclampsia was probably the most common pre-natal complication, an acute life-threatening illness which in its final stages causes convulsions followed by death. Eclampsia develops from untreated high blood pressure, and is entirely preventable with proper pre-natal care. Because of costs and other poverty related access problems including a lack of education on what services are available and where, many women do not attend pre-natal clinics therefore illnesses including hypertension cannot be detected. With poor nutrition, hunger, lack of clean water and repeated pregnancies due to marital rape, lack of access to healthcare information, pregnancy becomes a life threatening condition. But as one resident explained, everyone in Jalouzi is living in a life threatening environment as there is no emergency service.

‘Last Saturday a neighbour of mine died. She had an asthma attack but we could not find a way to bring her to a hospital. I have been traumatized this past three days as this woman died in my presence because there is not even a clinic here. There is no emergency service here. These kinds of emergency deaths are happening all the time. Even now across the street there is a woman who is in a bad condition vomiting and we do not know what we can do.’ [Pastor Remy">

There is an emergency ambulance service operating in PAP [115/116"> and some of the women had tried using it but never managed to get a response and even if they did they still had to get up or down the hill without proper steps and pathways. Flaurantin explains one response from a doctor and from 116.

‘A woman was near to delivery and I called the doctor. He told me to give the woman Buscopan but I could not. So I called the emergency 611 but they said they were in Carrefour and could not come now. I managed to find some people to carry the woman up the hill and we took a tap tap to MSF CURO at Delmas 33. The service is a good idea but there is not enough, they need more before they can call it a service for PAP. When we arrived the doctors told us the woman was very sick with high blood pressure and eclampsia.’

As I understand it Buscopan is a drug to reduce muscle spasms of the gastrointestinal tract and according to my google search not recommended for pregnant women. A strange medication to suggest to a woman in labour and disturbing disregard for patients.
The reliance on CURO and MSF across the city was enormous. The MSF manager of CURO* explained that the capacity in the public health system did not extend to more complicated illnesses which is where MSF is now focused. Nonetheless he admitted that it was not always easy in an extreme situation to define ‘emergency’. The risk factors designated as emergency complications by MSF ranged from multiple partners [increasing risks of STIs">, poverty [poor nutrition and food security">, and age related risks, that is girls under 16 who were rape victims and are referred by MSF France which runs a programme to support rape victims in Cite Soleil. And cholera remains a significant health issue so much so that MSF has a dedicated cholera facility at the emergency center as well as a separate hospital. On a positive note MSF is predominantly staffed by Haitian doctors, nurses as well as auxiliary staff and most importantly is staffed 24 hours a day. The day I visited there were three sets of tiny premature twins who were being cared for under a system called ‘Kango’ where the baby is placed skin to skin on the mother’s stomach. The very premature babies were in incubators and their mothers were allowed to stay until they reached full term weight which could be as long as three months. On average they deliver 600 ‘at most risk’ babies per month.

In addition to the risk factors mentioned by MSF, women complained that quite often there were no doctors available in the public hospitals, a fact supported by a health official I spoke with.

‘Sometimes there are no doctors or they have no medicine or there is no electricity. Sometimes it is all of these.’ [Anon official">

Another pediatrician described the General Hospital and other public hospitals as ‘very sick’ often decrepit with no anesthesia, no ER and no supervision. Both Rea Dol and Flaurantin Ansie spoke of their experiences of being turned away from hospital during labour because there was no doctor. Flaurantin explains as follows:

‘ I took a pregnant woman to one of the hospitals the Ministry of Health said we can use free of charge. When we arrived, the hospital told us we have to pay 4,500 goudes and if it is a complicated birth then it’s 10,000 goudes. I told them they are thieves because it is supposed to be free for poor women. I then took the lady to Petit Frere near Tabarre where she gave birth.’

‘In another case a woman had a breech baby but by the time I arrived the baby had died. I was not able to deliver the baby so I took the woman to the hospital. They said there was no doctor. I went to another hospital and again I was told no doctor. I then took the lady and laid her on the street and covered her. She was in labour even though the child was dead. I stood up on the street and said who will help this woman. I blocked a passing car and asked the driver, a man, to look at this woman. So he drove us to Delmas 18 MSF where they accepted the woman and gave her the treatment she needed.’

Another woman reported going to five hospitals when she was ready to deliver and being repeatedly refused until she found one that was willing and able to accept her. Women also reported that many private hospitals refuse emergency patients if they cannot pay and in one instance a woman was turned away because she was short of 100gdes and later died. The family sued and the hospital ended up having to pay US$36,000 in compensation.

MSF is not the only medical NGO used by Jalouzi residents. St Luc and Petit Frere et Soeur in Tabarre are also free but are even further away than the MSF facility. However many of the faith based hospitals have come under threat as the Haitian government makes it more and more costly for them to operate by for example having to pay astronomical sums for importation of drugs and other medical equipment. Some of the nurses I spoke with said their salaries had already been cut by as much as 19 percent and there were threats of redundancies in nursing and administrative staff plus a reduction of beds in some of the hospitals.

Because these are the only entirely free hospitals and generally with good care, they are over subscribed serving hundreds of thousands. Any reduction in services would entirely undermine the already inadequate health service for the majority of PAP residents.

As one health official put it to me - for the rich, Miami can as well be included as part of Haiti’s healthcare provision. The time it takes to fly to Miami International and drive to Memorial Hospital is probably less than the average waiting time of between 5 and 7 hours at any of the free hospitals. But for most other people just getting to hospital is physically exhausting, not to mention being sick at the same time.

ENDNOTES

[1] In PAP, MSF has the following medical centers in addition to CRUO; 2 MSF general emergency hospitals, 1 emergency stabilization center and 1 emergency Cholera response.

[2] Interviews conducted with nurses from various public, private and faith based hospitals in PAP. The nurses wished to remain anonymous.

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