Our goal is to create a beloved community and
this will require a qualitative change in our souls
as well as a quantitative change in our lives.
~ Dr. Martin Luther King Jr.
We see difficult things here. This is true. One of our patients is a prisoner who was brought to our hospital yesterday. The guard who brought him in shackles him to the metal part of the bed, and then disappears. We have no way to unshackle him. The prisoner is confused, with a very high fever. His right ankle is shackled to the bed, and his body rotates like a door around the hinge which is his ankle. In his confusion he rotates off the bed and face plants into the not so clean floor. We lift him up and the nursing staff attempts to change the sheets that are soiled. They are inevitably soiled far faster and more efficiently than any response this hospital can muster.
His neck is stiff. We fear he may have meningitis. The fluid we draw from his back is fairly clean. It is labeled meticulously and finds it way to the hospital lab that we hope will have the capacity to analyze it. The next day we find out that lumbar puncture was a formality. The lab has little capacity, and few reagents to properly analyze the spinal fluid. Our patient continues to worsen without a clear diagnosis. The rest of the hospital is a huddle of wives and sons, and mothers in cramped quarters, hovering over their loved ones. They attend to them as best they can- a refugee camp of sorts. Outside, I see a rat scurry across the hospital grounds. It is perhaps the fattest living being on the compound.
This is the context in which our two UCSF fellows in Haiti live and work in a public district hospital. This is the context along with their Haitian colleagues they attempt to transform. It could get overwhelming being here, and it does occasionally for our fellows. Despite this, there is a sense that transformation can happen because it has happened before and we have seen it with our own eyes. It happened in St Marc, another district hospital on the west coast of Haiti.
A few days after the earthquake, I spent three weeks at St. Marc Hospital. Hundreds of patients had fled Port au Prince and landed in the surrounding hospitals with the hope of getting some care. At St Marc we found a parade of hobbling and immobile femur fractures, muscle breakdown and spine injuries.
I have a picture on my phone from that week. It is one of our patients with a femur fracture. She is recovering, and smiling. Out of the frame is the 60 or so other patients squeezed into that room. The paint is peeling off the wall in the background. There is tape on the wall behind her to label the mats on the ground.
Nearly four years later I found myself back in the same room. This time, it is transformed into the location of a beautiful conference room for the new Haitian Family Medicine Residency. A confident Haitian intern presented an eye cellulitis case and a compelling discussion ensued with the 15 Haitian residents, their Haitian faculty and us. The Haitian leadership was strong. Clarity and competency were replicating themselves in the education of a cohort of new physicians who were committed to their country’s poor. The everydayness of a great case conference and a space for continued scholarship and sculpture of young Haitian minds to serve the poor in a room that was once a makeshift bare bones storage space for patients, is worthy of balloon and streamer celebration. Even the light seemed to flow in differently, with a bit more hope four years later. This also got me thinking of the reasons why St. Marc has been so excellent in beginning the transformation.
A few lessons for global health can be gleaned from the progress here.
1) Start small, and local. There must be a couple of individuals who are the anchor for deep change. A little bit of change from a couple of people can ripple into deep change. If there are one or two strong leaders who also understand the context, ripples of good can spring forth. This is pretty obvious. In Ashoka language (social enterprise), these individuals are the “changemakers”. They often exist in the local context. At Zanmi Lasante, the sister organization of Partners in Health, we continuously witness Haitians going to Rwanda to improve quality there, or Rwandans going to Liberia to transform systems there. In St Marc, Dr. Kerling and Dr. Patrick, the two residency program directors, seed so much inspiration into all the other staff, that it is easy to notice the overall shift of the site. It was present that day during the case conference.
2) Investment in the public sector can yield significant rewards that build momentum decoupled from donor priorities. In the aftermath of the Haiti earthquake, based on United Nations estimates, bilateral and multilateral donors dispersed over 6 billion dollars of aid for recovery, but just 10 percent of it went directly to the Haitian government. According to a recent article in Health Affairs, only 0.9 percent of immediate relief went to the Haitian government. The focus on health system strengthening that is now commonplace vocabulary among donors of global health, must include support to build up the public sector in low and middle income countries. Despite how often health system strengthening is lauded as a worthy goal, the reality of funding is different. Based on United Nations estimates, bilateral and multilateral donors channeled $6.04 billion in humanitarian and recovery funding to Haiti from 2010 to 2012, but disbursed less than 10 percent of it directly to the Haitian government. Just 0.9 percent of immediate relief aid right after the earthquake (totaling $2.41 billion) made it directly to the Haitian government. Even the local NGOs and businesses were excluded: less than 0.6 percent of that $6.04 billion was invested in Haitian organizations and businesses. One of the top bilateral donors in Haiti awarded only 1.4 percent of its contracts to local companies. St Marc is an example of channeled public funding that yields transformative results.
3) International solidarity. Nothing beautiful and lasting can be done alone. It also cannot be done immediately at scale nor should it. We need human relationships, built over time to transform systems. In global health the people we are trying to serve are by definition poor and sick. They are not the best constituency to organize themselves. This leads to policies and programs that don’t really have the people we serve at the table. I recently saw the film “Dallas Buyers Club” about the early days of HIV. Matthew McConaughey plays Ron Woodroof, a cowboy who contracts AIDS in an era where the FDA had not yet approved any medication. He goes on a personal mission to travel around the world and gain access to medications in the early 1980s. He is fearless, aggressive, and does not yield to the medical establishment. The story of the HIV movement has been told so many times, in so many elegant ways. Almost all versions detail how the afflicted pushed the establishment. Populations most devastated raised their collective voice and pushed. They had some political power because many were White or middle class. When they gained access, they aligned themselves with other HIV patients around the planet. Of course this is a simplified version of the story, but it illustrates to some degree what is happening in the immigration reform movement in the United States. Think tanks, policy advocates, academic scholars, and NGOs are certainly shaping the conversation. But the most compelling immigrant rights advocates I have witnessed are the “DREAMers“- the undocumented youth who came here when they were very young through no decision of their own. Like the protagonist in Dallas Buyers Club, the DREAMers are fearless and have the most to gain or lose. Their fight is intimate, personal and profound in a way that a Global Health movement confined to the walls of academia, or halls of the Gates foundation, or board rooms of the World Bank can never be. Those of us who are front-line workers but straddle the globe and work closely with our colleagues from Haiti to Liberia who have dedicated their lives to healing poor, sick patients and poor, sick systems would do well to imbibe their stories and tell them again and again and make sure they have the space to tell their story themselves. It is a small piece of having the most afflicted and the most poor at the table in a Global Health context that is almost inherently hierarchical, exclusionary, and fragmented.
Partners in Health names this type of international solidarity as one form of “accompaniment.” Martin Luther King, Jr speaks of a beloved community which “requires a qualitative change in our souls as well as a quantitative change in our lives.” Buddhist teachings emphasize the importance of a “sangha”, a community of noble friends committed to each other as easily and fully as the right hand is committed to the well-being of the left hand. All of them speak to the importance of an international solidarity around shared, human, transformational values. Joia Mukherjee, the CMO of Partners in Health, is fond of saying, “we need mothers in Boston or San Francisco advocating for safe child birth for women in poor settings across the globe because they know first-hand the importance of being pregnant without the fear of bleeding and not stopping or losing the baby you hold so dear.” Or the AARP(American Association of Retired Persons) or older people in the United States advocate for a safety net for old people across the globe- something like social security or medicare because they understand the benefit so well. This type of international solidarity would make Global Health more of a movement. It is also the type of solidarity that St. Marc has benefited greatly from. Money is needed, for sure. But also a solidarity that brings the decisions shaping global health down from the ivory towers, the policy tanks, and the world banks. The beloved community that MLK Jr. describes requires a quantitative restructuring of how Global Health decisions are made and a qualitative, more inclusive shift in the souls of all of us, especially those of us claiming to be experts in something so vast and expansive and important as Global Health.
~ Dr. Sriram Shamasunder