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At St. Catherine’s Hospital, Cite Soleil, Haiti

“Poverty has a way of stripping a person from their dignity. It teaches them that defense mechanisms are their weapons, and pride is their currency. Poverty strangles, decimates, and poverty devours.”

— Maria Atkinson–Going Forth

St. Catherine’s Hospital–Cite Soleil. Photo by John Carroll.

St. Catherine’s Hospital in Cite Soleil could be one of the world’s greatest teaching hospitals. I remember St. Catherine’s 30 years ago when it functioned much better than it does today. I remember St. Catherine’s when Dr. Paul Blough of Peoria delivered 10,000 babies there in a decade or so. Right now St. Catherine’s is in shambles, consisting of some scattered buildings with a few patients lying inside the wards. Cockroaches crawl around the floor outside of surgery.

It doesn’t need to be this way.

St. Catherine’s is surrounded by a slum which is home to hundreds of thousands of people who have been treated negligently by the outside world. Their water is dirty, the streets are dirty, neighborhood corruption is dirty, and the UN in Soleil has killed innocents with dirty bullets shot from the ground and the sky.

Because they live in a horrible physical environment with no infrastructure, people in Soleil get sick for stupid reasons from stupid diseases. And they often become sicker because of delayed or nonexistent medical care. These people can present with any stage of illness…early-stage, mid-stage, or end-stage disease. Thus, Soleil is a laboratory of human illness in all of its forms that would have made Josef Mengele proud.

So what would have to happen for St. Catherine’s to become a functional state-run teaching hospital? The Haitian government needs to sink money in the hospital and improve the physical structure, hire competent doctors, nurses, and associate staff, and pay them fairly and on time. And St. Catherine’s needs to serve the people of Soleil and the adjacent slums at no cost.

St. Catherine’s needs to provide the basics. The hospital has to have electricity 24/7. It has to have basic sanitation services. And it needs to provide basic medical treatment and diagnostics which would include medication, IV fluids, oxygen, labs, and X-rays.

Surgery and anesthesia need to be available 24/7. The ER needs to be much larger and staffed appropriately for the thousands of medical emergencies that occur daily in Soleil.

And there needs to be good security with crowd control to keep the narrow hospital corridors open.

A program could easily be set up where resident physicians from all over the States would come to St. Catherine’s for a month to learn what these Soleil patients could teach them. And there could be a reciprocal program where a Haitian resident physician from St. Catherine’s could study for a month at a medical program in the States. For example, a resident physician from the University of Illinois in Peoria could work for a month in Haiti while one of the Haitian residents at St. Catherine’s worked in Peoria. Both of these physicians would learn from a new environment and would be able to apply what they learned when they returned home.

What would young physicians (both Haitian and foreign) see at a functioning St. Catherine’s Hospital in Cite Soleil?

Pediatrics

Haiti has one of the highest infant mortality rates in the world. (The infant mortality rate is 59 deaths for every 1,000 live births.) There are many premature births in the slum and many of these babies are born at home. St. Catherine’s could have a very active Neonatology Service.

Rotating through the pediatric ward at St. Catherine’s would be like doing a mini-fellowship in Pediatric Infectious Disease. In just one day, the resident could treat sepsis, pneumonia, meningitis, congenital syphilis, HIV, tuberculosis, typhoid fever, cutaneous anthrax, vectorborne diseases (Zika, malaria, dengue), intestinal parasites, a potpourri of skin infections, and chronic osteomyelitis.

Soleil is replete with malnourished kids. One-hundred thousand Haitian children under five years of age suffer from acute malnutrition, while one in three children is stunted, or irreversibly short for their age. Malnourished kids don’t have immune systems that function well. And when they get sick, they are fragile and need to be handled with care.

Malnutrition comes from poor socio-economic conditions and comes in different flavors. There is marasmus and kwashiorkor and one child may have both types. The young resident physician can see what lack of protein, calories, vitamins, and minerals do to the child. They can see the sad pathetic look on their faces, they can feel their sparse orange hair, they can see their bodies swollen with edema, and they can guess what vitamin these kids are lacking as their skin turns colors and peels off.

The pediatric resident would see the danger of untreated strep infections as they watch Haitian teenagers struggle with congestive heart failure from destroyed rheumatic heart valves. And the residents expertise in heart murmurs would skyrocket listening to heart sounds and murmurs they have never heard. Young physicians could also examine children with congenital heart defects that were never operated and see why cyanosis occurs as blood flows in the wrong direction.

Thus, Soleil’s children (unfortunately) have much to offer the young resident physician. And a functioning and accessible St. Catherine’s has much to offer the children of Soleil.

Obstetrics/Gynecology

Haiti has one of the highest maternal mortality rates in the world. According to the most recent estimates by UNFPA and partner UN agencies, a woman in Haiti has a one in 80 chance of dying due to pregnancy or childbirth, compared to the region-wide risk of one in 510.

Only 36 percent of births in Haiti take place in health facilities, and only 37 percent of women give birth under the care of a skilled birth attendant – such as a doctor, nurse or midwife – who is able to recognize and address complications. I doubt Soleil’s statistics are better.

The women in Soleil need to deliver their babies at St. Catherine’s under controlled circumstances. C-section needs to be available at all times.

There are highly effective interventions for all four of the major causes of maternal death – severe bleeding, sepsis, eclampsia, and obstructed labor. All of these disasters happen in Soleil and most of the time the woman and baby are on their own–unable to get access to care.

Internal Medicine

Haitian adults in the slum are often thin because they don’t “find enough food”. But being thin makes them easy to examine. And that is good for the fingers of the young physicians who are adept at the computer keyboard but never learned the physical exam.

Haitian neck veins don’t hide under excess adiposity. The examiner can see these vessels and their fluid levels with their normal and abnormal undulations. Swollen lymph nodes are easy to feel and are rubbery, mobile, draining, or fixed and hard and give clues to their cause. Lungs are easy to auscultate and check for egophony and whispered pectoriloquy. The point of maximal impulse of the heart can usually be located and heart tones can be easily heard. Murmurs are no longer mysterious but can be quantitated and classified. Abdomens are easy to palpate and rock hard liver borders can be contrasted with soft pulsating ones.

The Internal Medicine patients of St. Catherine’s would include neglected people with uncontrolled hypertension which have damaged their brains, hearts, and kidneys.

STD’s and tertiary syphilis abound. AIDS and TB are common.

End stage malignancies are universal in Soleil as is the need for pain medication to control pain at the end of one’s life. I wonder if the young doctors would flinch or wonder why there were no narcotics for the 40-year-old lady with end stage metastatic cervical cancer and pain so severe that she could no longer get on the back of a motorcycle.

Surgery

A rotation on the surgical service at St. Catherine’s would be mind blowing. Absolutely everything cured by a Bard-Parker scalpel comes through the doors from a perforated viscus due to typhoid fever to a collapsed lung from the Soleil Knife and Gun Club.

Conclusion

St. Catherine’s Hospital in Soleil could become a great hospital and a great teaching hospital. The population in the slum would benefit as would young doctors who will be taking care of us in a few years.

My hope is that young resident physicians, both Haitian and foreign, who would work at St. Catherine’s, would see with their own eyes the correlation between poverty and disease.

They would see what happens to a population when they are denied basic rights of food, water, electricity, and education.

They would see what happens to people with no income.

They would see how poverty breaks up families and causes chaos.

They would see how poverty drives people insane. They would see women talking to themselves as they try and give away their babies to someone/anyone who can take care of them.

And I would start a course at St. Catherine’s called “Poverty and Disease in Cite Soleil.” It would show the cause and effect of poverty and the misery and suffering from unnecessary disease in Soleil. (We cannot continue to blame the poor patient for his illness.) I would require that the doctor who discharges his patient back into the slum, visit the patient’s home just once and feel the heat and the misery inside the shack. These doctors need to be appalled and have their souls shaken.

As it is the doctor’s duty to use a stethoscope or an ultrasound machine, and look at labs, and study the chest x-ray, it is also their duty to ask why this disease is occurring. What is the root problem? Why are these people sick and what can the physician do about it in a larger societal context? Physicians need to be taught that is not ok to be silent on these “extra-medical” issues because these issues directly influence the health of large populations of people–not only in Soleil but everywhere.

More articles by:

John A. Carroll, M.D. is a physician working in Port-au-Prince.

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