(Figurative) Mountains Beyond Mountains

Over the past three plus weeks, my general participation in the screening program and my slow improvement with regards to my ability to make small talk in Kreyol has made me feel increasingly connected (or attached) to this patient population. The results for the first group of women we screened have actually returned, and in a recent meeting, we were formalizing the exact course of action to be taken for those women who tested HPV positive. While new evidence available in the States indicates that immediate visualization of the cervix via colposcopy is the logical next step, things are not so clear-cut here… a fact that was, at first, somewhat difficult for me to understand.

Since my arrival, I had a certain idea about the clinic and cervical cancer screening, a view on how things should be done, what was necessary, etc. I was convinced that my potential way of doing things (or the way things are done at home) would be more beneficial or effective or whatever. But things are very obviously not the same here as they are in the States, and the people who live and work in Haiti are more likely than I to know what will and will not work, knowledge that I have only begun to appreciate. Not to say that the overall process is not (very frequently) frustrating. With regards to our discussion concerning appropriate follow-up for HPV positive women, Dr. Merisier continued to insist that we perform Pap smears on every woman prior to colposcopy, even though this would be a complete waste of time, money (that many of these women do not have) and resources (Pap smears miss a lot of the lesions colposcopy can readily detect, not to mention this additional test requires women to return to the clinic an extra time, thereby increasing the possibility that they may not return again and subsequently be lost to follow-up). This decision annoyed and surprised me; I just could not see the logic, that is, until things were explained more fully. Not surprisingly, the test’s true necessity is culturally related. As Pap smears are still considered the standard of care in Haiti (despite evidence to the contrary elsewhere), not performing the test could open Dr. Merisier and the clinic to scrutiny and difficulty with the health ministry (whose jurisdiction is irregular and fair from objective).

So, basically I am slowly learning that although things often seem straightforward. they are most certainly not… and unfortunately it often occurs that there are no easy solutions. Yet another example: Leogane, though not nearly as large (or overwhelming) as Port-au-Prince, is still a fairly large city with a large population desperately in need of health care. As of now there is no functional hospital (the only affordable hospital, Hopital St. Croix, recently closed… at Hopital Cardinal Leger patients will not be admitted unless they pay upfront, regardless of the circumstance). When Dr. Merisier needs to perform a surgery, or even an emergency C-section, he has to wait for the arrival of an anesthesiologist from Port-au-Prince (at least an hour away… but taking into account “Haitian time,” it could actually be several hours… back in Novermber, Dr. Merisier was forced to perform a C-section with mere local anesthesia). There are no anesthesiologists here in Leogane, no one on overnight call, no one available for surgical emergencies.

Why not train a local nurse to at least be available afterhours for such emergencies? Great idea! Except he/she would need an anesthesiologist to train under and all the physicians have refused to participate in such training, seeing certified nurse anesthetists as competition. They (somewhat understandably) do not want to jeopardize their job security. Ok, fine. We can bring anesthesiologists from the States to train one or two nurses… but where exactly will this training take place? Hopital Cardinal Leger is where the surgeries are performed and they cannot just tell the current anesthesiologists to stop showing up for surgeries. So, though there is this dire need and although there are potential means to fill it, a countless number of obstacles make something seemingly simple near impossible. Oftentimes it seems that for every good solution, there are five or more reasons why said solution would not actually work. Sigh.