Global Surgical Need
More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. The study aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission’s vision.
The Commission modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability and found that at least two-thirds (4·8 billion people) of the world’s population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western subSaharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access. Interpretation
The bottom line is that most of the world’s population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.
Although Haiti was not specifically addressed in this article, it would be safe to assume that it would be included in the category where 95% of the population does not have access to adequate surgical care. Please reference a related post titled, “I’d rather have HIV than a broken leg.”
Received a note today from Hopital Adventiste Project Manager Dan Brown stating, “If all goes well we will be moving in on Tuesday, Sept. 29th!” He was referencing, of course, the long-awaited renovation to the new operating theater. To all past and future volunteers and staff, this is great news indeed. The banner image above shows the newly installed doors leading to the 3 new operating rooms. Dan and his crew have managed to pull off a first class effort as evident in the images below. We are looking forward with great anticipation to our trip next month.
Clean Hands Save Lives
The following article was written by Merrill Chaus, RN and was originally posted on the Team Sinai Haiti blog. Merrill has visited Haiti on numerous occasions and recently wrote an article titled “Dark Side of Doing Good” for haitibones that is well worth reading if you have an interest in volunteering overseas.
On August 2, 2015 Operation Rainbow/Team Sinai conducted a nursing workshop at Hôpital Adventiste d’Haiti in Carrefour. The idea for this conference evolved in response to research and interviews for my MPH thesis, in which I explored local health care worker perceptions regarding short-term surgical missions. Recommendations from the local healthcare workers included a desire for more nursing education in the local language. The purpose of this 2-day conference was to honor this request. Topics of interest suggested by the nursing director included: Infection Prevention, Role of the Operating Room Nurse, and Care of the PACU (Post-operative Care Unit) patient. In addition to these presentations, Dr. Francel Alexis gave an informative lecture on TSF (Taylor Spatial Frame). There were 70 participants, which included nursing students from the university, HAH nurses, housekeeping, PT and a physician.
Our nursing instructors Johanne Sequin and Nadine Henry, both from Shriners Hospital in Montreal, Canada gave 6 talks in French and Creole. Johanne has 40 years of experience as an Operating Room Nurse and Nadine has 30 years experience in pediatric and adult PACU. Recruiting experienced instructors that spoke the local languages was key. Brittany Herzenberg, our administrative assistant, kept us on time and organized. She even secured a small generator when we lost electricity to the LCD projector.
The handrub formulation is evidence-based, utilizes local resources and provides access for healthcare providers at point of care. Four local nurses formed an infection prevention committee to oversee production and utilization of the handrub.
After a hospital wide assessment, dispensers were placed at strategic locations away from electric outlets, medical gases and light switches. According to Mac, the Haitian volunteer coordinator, dispensers are actively being used and refilled when necessary.
Break out sessions were arranged so participants could practice: donning and doffing PPE (Personal Protective Equipment), proper hand hygiene technique and simulate real case scenarios that may occur in the OR, PACU or wards. Course certificates were given at completion of each workshop (see banner image).
The conference concluded with a demonstration on how to make alcohol based handrub according to World Health Organization guidelines. We are thankful for the invaluable support of the administrative staff. HAH provided two air conditioned rooms and lunch for all participants.
Team Sinai will be returning to HAH this January for our annual surgical mission, this time with an emphasis on foot and ankle surgery.
Edward Martin, HAH Administrator
The following update was written by Edward Martin, Administrator of Hopital Adventiste d’Haiti (HAH).
The situation under which I was coming to the hospital was less than ideal. In the last quarter of 2013, the hospital ended up losing a very important revenue stream which sent it on a downward spiral. That service accounted for over 60% of its operating budget and since the other hospital services weren’t generating enough revenue to cover the difference, the hospital was unable to meet its financial obligations faithfully. The impacts were felt almost immediately and life for the staff became extremely difficult.
I formally took up my position as Hospital Administrator on September 2, 2014. On the third day of my post, I began meeting with my staff to begin planning the way forward. As an administrator that has worked in sub-Saharan Africa for over 9 years, I have been involved in many hospitals, clinics and rural healthcare center, and while the challenges I have experienced in those countries were similar, rarely have I come across an institution that can accurately be termed “a diamond in the rough.”
As was mentioned, the hospital has had challenges financially. It has not only impacted the ability to compensate the employees in a timely manner, but also to meet its obligations to various suppliers, government entities and service providers.
- We have conducted a right-sizing exercise that helped to more accurately reflect the proper staffing levels needed.
- Upgraded accounting software and trained staff on the new accounting procedures.
- Collapsed and centralized similar services which called for less staff but greater oversight over assets and personnel.
- Established Central Stores for better accounting of medication along with medical and departmental supplies.
- Restructured the business department so that employee’s strength is aligned with the designated position. We haven’t fully finished with the restructuring within this department, but we are close.
- With the coming of Mr. Jean Robert Julien (Bob), we have been able to gain much more momentum in the restructuring of the business office.
Over the past 34 years of the hospital’s existence, signs of aging can be seen throughout the hallways and in every area where services are rendered. Many of our departments present a less than ideal space for care to be provided and general maintenance is needed on most of the hospital’s utilities, whether it be rusted pipes which are springing leaks or exposed electrical wires. However, with the coming of Dan Brown, our Facilities Manager, many of the growing structural concerns are being addressed.
- Renovations of the brand new Operating Rooms are near completion. This project has been the brain child of various individuals and organizations such as Dr. Scott Nelson, Loma Linda University Health and Florida Hospital.
- The Laboratory Department is also undergoing renovations and is also near completion. Our hope is to become a reference lab for the country. Our highly motivated laboratory staff have been undergoing intense training in preparation for the transition into their new area.
- Minor renovations are being done currently on the plumbing and electrical cables until a later time when a complete overhaul of the system can be done.
I am not proficient in French, however I have a very basic understanding of Creole and am able to communicate at a very standard level. However, when I first arrived at the hospital, I heavily relied on my top administrators and secretary to help translate for me. As you can imagine, it has been very difficult trying to get my ideas across, especially when trying to guide an institution that is gravely under resourced and lead it toward becoming sustainable.
As a single man, it has been relatively easy for me to relocate to different counties whenever opportunity came knocking. My travels have brought me into contract with many inspiring personalities and fascinating places. I wouldn’t trade my experiences for anything. At the same time, I must admit, there are moments when the excitement of experiencing the world as a single person loses its luster and unfortunately for me this is one of those times. All I can say is that Haiti, with its rich culture and polarizing moments was never meant to be experienced alone.
While the hospital is beginning to transition out of an extremely difficult period, I am very optimistic about its future and the objectives we have set out to accomplish. In order for the institution to be successful, it will continue to require a collaborative effort between the Board, hospital administrators, staff and other supporting partners. Furthermore, as part of the hospital’s overall strategy to expand its services while generating much needed revenue, we will be joined by new team members. One being, Dr. Alex Coutsoumpos, who will be taking up leadership as the Chief of the Perioperative Department while assisting our Medical Director in the coordination of medical activities. Dr. Coutsoumpos is a US board certified general surgeon who, with his family, joined our team this summer. In October, we will have Drs. Kim joining us. Joseph Kim is a US board certified Emergency Medicine doctor and his wife Melissa is a US Board Certified Pediatrician. Joseph will be heading our Emergency Department and Melissa our Pediatric Department. To help re-enforce our accounting department and laboratory, we will soon welcome Gay and Rommel Malapit. Gay Malapit is a licensed Certified Public Accountant out of the Philippines who will be assisting in building up our Accounting Department. Rommel, with his background in Biomedical Sciences, will be essential in the continuity of training in the laboratory while leading our laboratory towards a Reference Lab status. Our new employees have committed themselves to working for the institution for anywhere from 2 to 5 years.
Short to Medium Term Vision
The short to medium term vision is one that is shared between many individuals and organizations who have committed themselves to the development of the hospital’s infrastructure and services. Some of these individuals include, but aren’t limited to. Dr. Richard Hart, Jerry Daly, Dr. Elie Honore, Pastor St. Pierre Theart, Dr. Scott Nelson, Dr. Terry Dietrich, Dr. James Matiko, Monty Jacobs, Dan Brown, Loma Linda University Health-Global Health Institute, Florida Hospital, Adventist Health International and the HAH Administration and Staff. Here are some of our short, medium and long term goals:
Phase I (1-2 years)
- Operating Room Renovations (near completion)
- Laboratory Renovations (near completion)
- Emergency Room Renovation ( pending)
- Hospital Main Floor Renovation (pending)
- Orthopedic Clinic Relocation and Renovation (pending)
- Dental Clinic Installation (pending)
- Embassy Clinic Installation (pending)
- Electronic Medical Record (in process)
- Telemedicine-Wound Care Program (in process)
- Haiti Air Ambulance Helipad (in process)
Phase II (3-5 years)
- Community Wing ( pending)
- Additional Land Procurement (pending)
Phase III (6+years)
- Establish health institutions in major cities throughout Haiti.
Finally, it’s important to understand that while we have supporters, the hospital fully runs its operations off of the revenue generated from its patients. This is the preferred model for us because it enables us to realistically plan for the future. If you would like to receive more information about the hospital, interested in potential visits or initiatives to subsidize poor patients, please feel free to contact myself (email@example.com) or our Volunteer Coordinator, Mackinson Christophe (firstname.lastname@example.org).
When “The Good Doctors” Leave
On March 7, 2010 the Los Angles Times published an article written by Joel Rubin entitled “What happens to Haiti when ‘the good doctors’ leave.” The main thrust of Joel’s article was “Emergency medical workers are becoming the de facto healthcare system for a country that has long failed to care for its own. Soon a ragged health network could be left largely on its own again.”
Unfortunately, we have now passed the 5-year anniversary of the Big Quake and Joel’s prediction has come to fruition, his post remains as poignant now as it did then. The devastation from that natural disaster affected approximately 3 million people and killed 220,000 according to government estimates.
What is the situation in Haiti now after several years of reconstructive efforts?
Before any sort of assessment of where Haiti is now, we should remember that on January 12, 2010, 60 percent of an already dysfunctional health system was destroyed in an instant. Furthermore, 10 percent of Haiti’s medical staff were either killed or subsequently left the country. This was, quite simply, a catastrophic event for the country.
The problem with healthcare in Haiti is that there is still no system, no structure, no plan – at least not one that has been widely implemented. What healthcare facilities exist are wholly inadequate – insufficient medical staff, support staff, equipment and treatment. It is left to medical NGOs and a few faith-based charity clinics to provide what they can.
Fortunately, at Hopital Adventiste d’Haiti we have retained “good doctors” including the Director of the orthopedic surgical program, Dr. Francel Alexis, born and raised in Haiti, who continues to strive to overcome obstacles with a dedicated team of local nurses, technicians and volunteer workers. Please consider supporting the restorative project at Hopital Adventiste.
Dark Side Of Doing Good
At Loma Linda University’s 2015 Alumni Postgraduate Convention seminar on Global Orthopedics, Merrill Chaus gave both a disturbing and challenging presentation entitled, “The Dark Side Of Doing Good.” Disturbing because, as a veteran of several overseas mission trips, I knew that I had personally violated many of her recommendations – challenging in the sense that I vowed to try and improve my track record in the future.
Merrill is a registered nurse and team coordinator for Operation Rainbow, a nonprofit organization providing free pediatric orthopedic surgeries to indigent children in underserved countries, mainly South and Central America, Mexico and Haiti. She has participated in over 20 national and international medical missions including 4 trips to Hopital Adventiste with her husband Dr. John Herzenberg, Director of the International Center for Limb Lengthening in Baltimore, Maryland. Merrill’s preparatory skills for these trips are legendary and she is more than qualified to offer the following advice.
Before the mission
Do consider national and religious holidays and elections before committing to mission dates.
Do inform local surgeon of your team’s specialties before arriving. The local surgeon needs time to match appropriate skillsets to patients’ needs.
Do anticipate and pack all supplies and medicines needed for a week of clinic, OR, recovery and follow-up care. Don’t strain the limited local resources.
Do ask local staff what lectures topics to prepare. Don’t assume that you know what they want to learn. Do extend lecture invitations to local doctors and community healthcare workers. Invite local experts to share their expertise and experiences.
Do not pack expired medications. Most NGO policies clearly state: No meds less than 6 months from their expiration dates.
Do take the Stanford/Johns Hopkins online course: Ethical Challenges in Short-Term Global Health Training.
Do take the Cultural Competency Online Course by Unite For Sight.
Do learn basic phrases in the local language. Do recruit volunteers who speak the local language to prevent miscommunication and reliance on interpreters. Do prepare patient education materials in the local language.
Do ensure your team is competent and credentialed to prevent spreading false knowledge and harmful practices. Good teaching skills are a plus!
Do consider recruiting a biomedical engineer to train locals on equipment maintenance and IT specialist to maintain computer networks.
Do fundraise to offset fixed hospital costs your team incurs such as water, fuel, electricity, oxygen, x-rays and IV fluids. Volunteer’s use of operating rooms may prevent local doctors from operating for a period of time. The local hospital is likely to need help to pay staff wages due to increased manpower demands.
Do cover up tattoos. Tattoos are often sported by gangsters and thieves in the developing world and may be threatening to patients.
During the mission
Do dress conservatively.
Men: scrubs/lab coat. Please no earrings or shorts.
Females: scrubs/lab coat, no sleeveless shirts during work hours.
Don’t smoke or drink alcohol on the hospital premises.
Do coordinate/cooperate with the local team and respect their hospital rules.
Don’t ignore or work around local staff. Work with them. This promotes good will and safe, ethical care.
Do identify who will provide follow-up care and consider reimbursement for service rendered in the future.
Do provide teaching moments during morning report, bedside teaching and conferences. Do less surgery and more training – “leave skills, not just scars.” Education is key to improving surgical capacity and sustainable change. The local staff needs skills to care for patient complications after teams depart.
Do wear identification badges with name and job title written in the local language. Locals have a right to know who is administering care. ID badges prevent misidentification and demonstrate collaboration and respect.
Do practice kindness, patience and cultural sensitivity. Locals may be reserved and intimidated. Engage them gently and practice cultural humility. Do remember that local staff and patients are watching you. Don’t do in the field what you wouldn’t do at home.
Do maintain high standards of care. Patients trust incompetent volunteers more than competent staff. This undermines trusting relationships.
Do document patient charts in the local language so that staff can follow patient progress and administer safe follow-up care.
After the mission
Do obtain contact information of the local surgeon providing follow up care.
Do give your contact info to the local surgeon.
Do leave casts, medicines and supplies for patient follow up visits.
Do continue sustained communication with surgeon and hospital.
Do plan a return visit.
Do consider a long-term partnership/training program.
Do consider using evaluation forms for both volunteer team and hosts.
Matching Gift Opportunity
Florida Hospital announces an exciting matching gift opportunity for Hopital Adventiste d’Haiti (HAH) available now through August 30, 2015. Plans, sketched below, are to renovate the existing polyclinic building and adding outpatient orthopedic services, dental care and optical services.
Orthopedic patients at HAH need a location outside of the hospital where follow-up care, consultations and minor procedures can be performed. Currently during orthopedic clinics the hallways of the hospital are congested with an over-flow of patients making it difficult for normal operations to occur.
Matching funds are limited and available on a first come first serve basis.
- Gifts of a minimum of $25,000 and a maximum $200,000 will be matched dollar for dollar.
- Gifts can be made as a pledge over five years with a minimum of $5,000 per year.
- Gifts or the first payment of a pledge must be made no later than December 14, 2015
As a tax-exempt community benefit hospital, Florida Hospital (pictured in title image) is dedicated to the great purpose of healing and enriching lives at home and throughout the developing world. Florida Hospital expresses its mission to extend Christ’s healing ministry to the world through Global Mission Initiatives (GMI). GMI is a department of Florida Hospital that collaborates with healthcare organizations in select countries where there is a desire for mutual accountability and sustainable improvement. GMI works with these groups in developing nations to identify long term needs, create strategic plans for improvement and assist in sustaining the effort.
Services provided through volunteers include: Donating equipment and supplies, organizing clinical education and training, fundraising for approved projects and programs, preparing and supporting medical missions, sharing process-improvement expertise, and supporting strategic-planning efforts. For example, Florida Hospital Global Mission Initiatives was recently asked to recruit a team of ICU Nurses and Respiratory Therapists to participate in the care of the conjoined twins recently separated at Hôpital Universitaire deMirebalais.
Dominik Rog’s Trip To Africa
It is well known that this website is dedicated primarily to the latest news as it relates to Hopital Adventiste d’Haiti (HAH). However from time to time we will feature articles dealing with volunteer experiences outside of Haiti. Dominik Rog is entering his senior year of orthopedic surgery residency at Loma Linda University and has been accepted into a postgraduate upper extremity fellowship in Louisville, Kentucky.
Our trip began with a quick stop to the CURE hospital in Addis Ababa, Ethiopia. Clinical activities included touring the facilities and assisting in clinic. I had an opportunity to work in clinic with one of the Ethiopian CURE staff members. The range of pediatric orthopedic pathology seen is quite different from a clinic in the United States. Notable are the amount of burn contractures, sequelae of untreated tuberculosis, neglected clubfeet and rickets. Several patients presented with malunited fractures. One of the common factors present amongst these patients is very poor or no access to healthcare. For this reason the CURE staff is often faced with the late presentation of problems that are normally treated at the acute stages in the developed world. The more common issues present in pediatric orthopedics are also seen daily in the CURE clinic (flatfoot, physiologic genu varum, etc). The CURE hospitals emphasize their role as a Christian ministry and in both Addis and Blantyre we had an opportunity to attend chapel services.
A majority of the trip was spent in Malawi at the Beit CURE International Hospital in Blantyre. Malawi as a country continues to be one of the worst in the world in terms of poverty, infant mortality and life expectancy. The population has a high rate of HIV/AIDS infection. It is, however, also a staggeringly beautiful nation, at least at this time of year.
At the CURE hospital, I had an opportunity to work in the clinic and on the ward, as well as in the operating room. In both the ward and clinic we saw patients with chronic osteomyelitis, which is quite prevalent in Malawi, neglected fractures, avascular necrosis secondary to HIV, sequelae of untreated septic joints including growth arrest and AVN and tumors. Much of the pathology present is similar to that seen in Ethiopia and we again saw many patients with burn contractures and neglected clubfeet. Although I did not have an opportunity to assist in the treatment of any patients with chronic osteomyelitis in the OR, I was able to see several patients on ward rounds. Chronic osteomyelitis is treated in a relatively unique fashion in Malawi. These patients undergo sequestrectomy and I&D, and the wounds are then left open and treated with honey, which has antibacterial properties – antibiotics are generally not used.
The CURE hospitals support some of their operating cost by seeing and treating private patients for a fee. The children are treated at no cost. The adult patients in the private clinic also present some unique pathology. Like the children, many adults have poor access to healthcare, including those who are able to afford being seen by CURE, and often do not present until several months or even years after their fractures. Untreated femoral neck fractures in adults is apparently a relatively common problem and is one of the reasons that total hips are done in both Malawi and Ethiopia. As in the children, untreated and chronic osteomyelitis is a ubiquitous problem.
In the operating room I had the opportunity to assist in a foot burn contracture release with a FTSG, a supracondylar osteotomy, anterior tibialis transfer, Rush rodding of the femur for osteogenesis imperfecta, as well a finger syndactyly release. In the other operating rooms I also had the opportunity to observe a total hip arthroplasty performed for avascular necrosis. The CURE hospital in Blantyre has three functioning operating rooms with all three running on most days.
During the trip in Malawi we also had an opportunity to travel to Malamulo Hospital (pictured in title image above) and tour the facilities. There we met with the medical director, the chief operating officer, and Dr. Ryan Hayton, who is one of the general surgeons at the hospital. Dr. Hayton oversees the PGY4 rotation for the general surgery residents at Loma Linda University. During the tour we viewed the emergency department, ICU, various wards, and the labs. Despite the drastic differences in resources between the Malamulo mission hospital and an American hospital, they are able achieve very good outcomes when looking at infant mortality, maternal mortality, postoperative survival, etc. It was quite interesting to learn that the surgery team at the hospital successfully performed an Emergency Department thoracotomy. The patient passed away a day later in the ICU, but the rate of survival after such a procedure is quite low even in the best equipped American hospitals.
Overall this trip to Africa was quite an eye-opening event. I had an opportunity to experience firsthand not only the orthopedic needs in these two developing nations, but also the healthcare needs in general. Some of the pathology that is seen daily in the clinics of Ethiopia and Malawi can only be found in textbooks in the US or Europe. It was inspiring to see the orthopedic work that is currently being done by the CURE teams. The opportunities to make a difference are endless for the American orthopedic surgeon, whether for long term mission work or on shorter trips.
Red Cross In Haiti
This story was reported by Laura Sullivan on behalf of a partnership between NPR News Investigations and ProPublica, an investigative journalism organization. You can read or listen to more of the report on NPR’s site. You can also read more from ProPublica: How the Red Cross Raised Half a Billion Dollars for Haiti and Built Six Homes.
When a devastating earthquake leveled Haiti in 2010, millions of people donated to the American Red Cross. The charity raised almost half a billion dollars. It was one of its most successful fundraising efforts ever. The American Red Cross vowed to help Haitians rebuild, but after five years the Red Cross’ legacy in Haiti is not new roads, or schools, or hundreds of new homes. It’s difficult to know where all the money went.
NPR and ProPublica went in search of the nearly $500 million and found a string of poorly managed projects, questionable spending and dubious claims of success, according to a review of hundreds of pages of the charity’s internal documents and emails, as well as interviews with a dozen current and former officials.
The Red Cross says it has provided homes to more than 130,000 people, but the number of permanent homes the charity has built is six.
The Red Cross long has been known for providing emergency disaster relief — food, blankets and shelter to people in need. And after the earthquake, it did that work in Haiti, too. But the Red Cross has very little experience in the difficult work of rebuilding in a developing country.
The organization, which in 2010 had a $100 million deficit, out-raised other charities by hundreds of millions of dollars and kept raising money well after it had enough for its emergency relief. But where exactly did that money go?
Ask a lot of Haitians, even the country’s former prime minister, and they will tell you they don’t have any idea.
Haitian Money Pit
After the earthquake in 2010 nearly $10 billion dollars of foreign aid was pledged to rebuild Haiti. Vikram Gandhi went to see just how that money is being put to use. This is his debrief from Season 3, Episode 7 of VICE on HBO.
It’s shocking and disappointing to see how little progress the average citizens of Haiti have made with the billions of dollars spent there. Like Vikram stated in the video, “People are going to have to start curating the way that they donate. There are a lot of places in Haiti that are smaller and often those places are incredibly successful.” Please consider donating to or volunteering at the relatively diminutive restoration project at Hopital Adventiste d’Haiti.