Transitions

The recent elections in Haiti were, as expected, wrought with accusations of fraud, outbreaks of violence, and general disarray. However, despite the cholera epidemic and continued refugee issues, the citizen gathered to vote for a new president to replace Previl. His supported candidate Celestin has been seen as both a continuation of the current corruption as well as a pragmatic leader. There are 18 parties involved, and opinion poll leader Mirlande Manigat, has filed protests with 11 others regarding irregularities. American rapper Wyclef Jean, although declared ineligible to run, is in the country and calling for a rapid response to these allegations, citing the risk of violence. And we won’t see preliminary results for another week. Such is the nature of transition.

At Sacre Coeur, we continue to respond to the cholera outbreak. The uprisings in Cap have settled down and in Milot, our volunteers are beginning to return. We still need supplies, and hopefully the relative calm will allow us to bring them in. Tim Traynor, our overall technical and construction wizard is back on site, and we are ramping up the sprung building inventory project. The political climate remains uncertain, however whoever is declared the new President will have unprecedented amounts of support to try to rebuild his country. The transition will be more vocal and chaotic than in the US, but it will occur.

And my own transition also begins. Those of you who have followed my blog know that I have been on a Sabbatical from my academic surgery practice as I returned to school and looked at new options. The times in Haiti, my children growing and leaving home, as well as other experiences have brought me new perspectives on the next phase. This past year, though difficult in many ways, has been a gift. But as I looked at new job opportunities, I was able to relate the lessons learned from the past and this helped me focus on the future.

Beginning January first, I will be heading west and relocating to Los Angeles to join Cedars Sinai Medical Center. I will be involved in the clinical transformation project, Cedars Medicine, as well as serve as administrative Vice Chairman of a large and talented surgery department. I am excited about the opportunity.


Every day we see a transition from the darkness of night to light of day and I will look forward to sunsets over the Pacific. I remain hopeful that a new day will also dawn for Haiti, although if history is any guide, there may be a few storms along the way.

Appreciate the Present

So, many bloggers will reflect on the upcoming Thanksgiving weekend, where families and friends will gather, eat and drink too much, and enjoy the present, even if some of the actions aren't completely healthy long term. It's important to appreciate the now, even as we plan for the future.

Over the last year, I've had more free time than in the previous 30 years combined. At first, I was antsy, that I needed to find something to do, besides school. My previous days as Chief of Surgery had been filled with a constant stream of information, decisions, triumphs. and challenges. Often times, I would forget to eat and by the end of the week, it seemed all seemed like a blur. There were certainly high points - a great conversation with family, friends, or colleagues; a warm Seven Stars roll; a patient that had turned their life around after bariatric surgery. Yet on balance, it was difficult to appreciate the now.



I recently came across the enclosed picture. It reminded me of the gifts I've been given recently with time. Chester and I have had numerous walks through the woods. When I was working, dog walks were fit in to a schedule and the goal was pretty clear. Now they are part of an experience of the day. I appreciate the changes in the sunlight filtering through the leaves as the seasons progess.

Even in Haiti, amid the chaos, we felt the presence of the moment. It is an awareness of the balance of powers and emotions. Trying to project into the future removes the chance to experience the now.

I will be returning to academic medicine in a more formalized role January first. There are several things I want to achieve long term. As I work to those goals, staying present will help me understand the motivations and needs of those around me, and how to work to reach those goals. And during my trip back to Milot in December, I know I will again be energized by those around me by staying in the present.

For those who are traveling - be safe...

Update from Sacre Coeur

I am sure many of you following this blog are increasingly concerned about the situation in Haiti. I have seen pictures of roadblocks and demonstrations in familiar areas of Cap. The state department sends daily updates, and I have also been communicating with Daven, the expat that I wrote about in September. He is working to ensure the safety of his workers against disease and the unrest. I am in awe of his commitment.

This morning, I received the following update from Dr. Peter Kelly, executive director. I am sharing it with you ver batem:

NOVEMBER 17, 2010
It's been a while since my last update about the situation at Hôpital Sacré Coeur. As most of you know we have discharged almost all of our earthquake patients and have approximately 10 waiting for prosthetic limbs.
Just as we were starting to implement some overdue renovations and outline our long term expansion plans we had the cholera outbreak. Immediately our hospital administration developed an emergency plan to handle 1,000 cholera patients and our community health department started teaching prevention in the surrounding areas. Other NGO's also collaborated with the Ministry of Health in implementing an extensive outreach program to contain the cholera. It was an impressive example of collaboration that did not exist before the earthquake. It was containing the cholera outbreak until the hurricane last week.
Once the hurricane hit the outbreak became an epidemic and has now reached Cap Haitïen and Milot. We have received over 100 patients over the past week and are expecting at least 1,000 more patients. Initially we were able to provide the care needed but then another catastrophe struck: FEAR. The people in Cap Haitïen blamed the UN for the cholera outbreak thanks to a news report and the people of Milot wanted to stop Hôpital Sacré Coeur from treating patients outside of Milot because they thought it would bring cholera to their community. Both fears are understandable but not based on fact.
We had 18 volunteers at our hospital and to insure their safety we had confined them to our gated compound for the past 24 hours. Once our administration spoke to the demonstrators it became obvious that the volunteers and staff were not in danger. They have resumed helping in the care of the cholera patients.
In any uncertain situation it is normal to fear for your own safety especially if you have never been to Haiti or Hôpital Sacré Coeur. There was a small group of first time volunteers who became very concerned about their ability to leave Haiti. They left our compound against our advice and thankfully were able to make it to the DR safely. The message we tried to convey to all volunteers was that the safest place in Haiti is Milot. The only danger exists on the roads to Cap Haitïen and in Cap Haitïen.
The reason I am mentioning this problem is that you may hear some negative reports about safety in Milot. Also I want to make other volunteers aware that we cannot always control their ability to leave Haiti. But I want to emphasize that we can control their safety!
At this time we have approximately 50 patients with cholera, 35 severely ill and 26 children. We are running low on supplies because of the road blocks and closed airport. For the same reasons we are now receiving patients that are near death because they couldn't get through the road blocks. We have over 30 volunteers willing to come and help but can't get to Haiti.
Our staff is operating on a skeleton crew because those in Cap Haitïen can't get through the road blocks so we are in desperate need for volunteers to help them and supplies. We are doing everything we can to try and find other ways to get supplies and volunteers
I want to end with a story about determination. Our medical director Harold Previl was at our board meeting in NYC. On his return to Haiti he landed in Port au Prince and heard about the unrest. He left his car in Port au Prince and road a motor bike to Milot because it was easier to get by roadblocks. He had to pass through 18 road blocks to get back to Milot 12 hours later. Another worry he had to deal with was that his daughters who attend school in Cap Haitïen had arrived in Cap Monday morning before the violence but were stranded in Cap Haitïen. Can you imagine what he must have been feeling and fearing? Thank God we have such wonderful and dedicated Haitian staff to guide our hospital. Please keep all of them in your prayers. Peter
Peter J. Kelly, M.D.
President

Please keep everyone in your thoughts. We will prevail.

Harry

Eye on the Future

The timing couldn't have been more symbolic. I was in school this weekend, and reviewing the inventory control project at Sacre Coeur with which I'm involved. We have been making good progress, the building is up, and we were coordinating logistics to get the hardware to Milot and begin installation and roll out. Potential infrastructure roadblock were identified and corrected. Things seemed to be on track. I was planning to head down in December. Twenty minuted before the presentation, I received two concerning emails.

The cholera epidemic reached HSC, and there were now widespread demonstrations in Cap, closing the airport.

The email from CRUDEM,updated the situation and asked for volunteers. The census was again swelling, this time with cholera patients. Fortunately, we had anticipated this scenario, and designated isolation areas in the tents, assured appropriate decontamination (you need dilute bleach, not just alcohol gel), and secured safe water for oral rehydration solution. We once again will respond to meet the needs.

The political unrest is not surprising. There has been no functioning government for almost a year, and frustrations are high. But I also learned that cholera had not been a problem in Haiti before, and the local citizens are blaming outsiders, including the UN, for bringing the disease to their country. They site early European explorers importing smallpox and syphilis to a previously unexposed populations in America.

I contacted several of my colleagues, as well as CRUDEM leadership. The response was what I expected - we have handled these challenges before and we will do it again. The demonstrations will die down, and we will get back to our mission of improving care and enhancing Haitian self reliance.

It's a good lesson for all of us. Crises are part of the everyday ebb and flow of life. By keeping our eye firmly of the long term goal, we will deal with the challenges of the now, keeping them in context.

For those of you who would like to volunteer, please contact Deb Motyl dmotyl@radiusmanagement.com. I would also be happy to speak to anyone about the logistics.

Big Results with Small Investments

As the destructive energy of hurricane Tomas was bearing down on Haiti this past Friday, a confluence of innovative intellectual energy and expertise was converging in Boston to discuss improving surgical care in the global context. I was at the "Role of Surgery in Global Health" program, where I learned more about programs and ideas to increase safe access to surgical services for the world's population. This was not an effort to bring high cost and complex procedures to areas that wouldn't benefit. Rather, it was the recognition that safe, basic, cost effective surgical services are a key component to public health. If you could have just one procedure that would reduce overall mortality in a population, what do you think it would be? Trauma laparotomy? Coronary artery bypass? Appendectomy? Actually, it is the availability of Cesarean section for nonprogressing labor. In addition to reducing maternal and fetal mortality, the incidence of debilitating fistula is reduced. Yet this requires anesthesia and clean operating theaters. We take anesthesia safety for granted in developed country, yet even when I was a child, anesthesia deaths and brain damage were more common due to unrecognized low oxygen saturations. The near universal use of pulse oxygen monitors has increased safety by orders of magnitude. Even though the cost is moderate by US standards ( about $1000), availability is limited in the areas of greatest need. What I learned was of a remarkable group that used business and political savvy to create an organization that would buy monitors in bulk from the manufacturers (who could then provide these at significant discount), and handle worldwide distribution and training. It reinforced my belief that the answer to many of our problems is not by throwing money at it, but by using human capacity for innovation and commitment to reach a goal.


I had more good news yesterday from Milot. The hurricane moved further west and damage was minimal. We are moving forward on our inventory project, the structure is erected, and here again, I've seen how we can bring in technology that will improve care at a moderate and justifiable cost. I'll fill you in on more as I plan another trip to Milot before the end of the year, this time to help with the integration, training, and roll out of the initiative. Thanks also to my classmates and instructors at the School of Public Health, who have provided invaluable insights and perspectives.



All this is in the background of some new directions that I'll be taking. I've appreciated the advice and support from many of you. It's certainly lightened my load and helped me focus on doing good things in the future.

How Much More Can They Take?

Just as things appear to be stabilizing, Haiti is again faced with crisis. The cholera outbreak, and the blunted response from the government again emphasizes the significant challenges in providing even basic needs. Several friends have asked me whether Hospital Sacre Coeur has been affected. From my reports, we have been fortunate that the outbreak is geographically distant. In addition, the proactive work of the local population and CRUDEM has provided improvements in the infrastructure, including water purification and sanitation. If the outbreak reaches us, I have no doubt that we will respond with the same zeal and organization as we always have.

Now we are faced with the prospect of a hurricane, whose track appears to take it over Haiti. I am glad that there will be some advanced warning, and hope that recovery and emergency supplies can be prestaged prior to landfall. As you have heard, the roads are in poor shape, and with extensive deforestation, the risk for mudslides that would limit access is high. Many in Port au Prince still live in tent cities with little protection from the elements. I fear for the outcome, but also realize that this is a country with tremendous resilence.

Susan Cu-Uvin, Professor of OB-Gyn and Medicine, and Director of the Global Health Intiative at Brown, forwarded this recent article, outlining the history of the Haitian government and with some explanation of current challenges. As is common in many struggling countries, the lack of true open elections that would provide a government that has credibility with its people, is a major issue.

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&-columns/haitis-200-year-economic-earthquake/

All of us have times when we feel overwhelmed, and wonder "How Much More Can We Take?" It is worse when we feel that it is beyond our control. Yet, as the Haitians have shown us, even in dire conditions, the basic human will to survive, and the faith that there is something bigger than us, provides hope and strength. Perhaps it is these types of challenges, as well as our own daily struggles, that teach us how to reach our full potential.

Haiti has been challenged enough. It is time to develop the new paradigm that will allow it to recover and thrive.


...and may it be so for all of us.