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Haiti in the Shadow of the Citadel

The Citadel staring down on the plain of northern Haiti. Photo by John Carroll.

The instructors of the course were Haitian physicians and US ED physicians and Physicians Assistants. The course was held at New Hope Hospital which is located a few miles south of Cap Haitien. We were outside on the large hospital patio. The patio had a roof but no walls which protected us from the sun but allowed a breeze to keep us fairly comfortable in the 90-degree heat.

I learned a lot through the excellent lectures, simulation workstations, and the extensive course syllabus. The course was rigorous and covered a large spectrum of medical emergencies from neonatal distress, obstetric complications, pediatric emergencies, toxicology, and adult and pediatric trauma.

From the patio, one could look for miles in a panoramic view in three directions over the lush flat land of Plaine du Nord. Looking west I watched young farmers with their hoes tilling the black dirt to plant banana trees and corn. Looking 15 miles south one could see the Citadel fortress high on top of a 3,000-foot mountain called the “Bishop’s Cap”.

The Citadel was built by Henri Christophe, a key leader during the Haitian slave rebellion (1791–1804), after Haiti gained independence from France at the beginning of the 19th century. This massive stone structure was built by up to 20,000 workers between 1805 and 1820 as part of a system of fortifications designed to keep the newly independent nation of Haiti able to repel any French incursions. (The French never returned.)

Legend has it that King Christophe would show his power and control to visiting world leaders by marching his men along the top of the wall of the Citadel. When Christophe would yell “jump” at a certain corner of the wall, the next man in line would leap to his death.

Haiti has always been a country of extremes. Essentially all of the students in this CALS course were online via a mobile device or laptop. The lectures were dignified with PowerPoint. As I listened to the instructors talk about pulse oximetry, sonography, and CAT scans, I couldn’t help but think how separated we were from the young farmers working only yards away from us in the Haitian sun. They were farming the same way that their ancestors farmed as the Citadel was being built over 200 years ago.

To offer critically ill patients, and trauma victims, and women having obstructed labor good medical care, Haiti has to have young professionals who know what to do. And this CALS course provided the universal basic steps at advanced life support combined with focused clinical pathways to give the patient the best chance at survival.

But the young Haitian physicians in this course cannot care for extremely sick patients by themselves. There needs to be structure in Haitian society for this to happen. Haiti lacks structure.

What is structure? It is good roads to transport the sick. It is electricity provided 24/7. It is clean water. It is diagnostic technology to help make the diagnosis of a head injury or an inflamed appendix. It is laboratories to analyze blood quickly. It is hospitals that function well to care for the patients even if they cannot pay. This is structure.

Haitian professionals and the bare-chested Haitian farmers are working in the shadow of the Citadel. The divisions in Haitian society are obvious. These two groups can benefit together only if structure is provided for both. The State of Haiti is responsible and is the only entity which can make this happen.

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

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