Steady supply of medical services begins to pressure Haiti's doctors

By Lois Romano
Washington Post Staff Writer
Thursday, March 25, 2010

Jerry and Marlon Bitar are prominent Haitian surgeons, identical twins who have done everything together for all of their 48 years. They both studied medicine in France, returned to Haiti in 2000 to take over a clinic serving low-income patients, and built a separate private practice that has given them national prominence and paid the bills.

In the weeks following the deadly Jan. 12 earthquake, they worked 18-hour days side by side, performing 900 surgeries and amputations free of charge between both of them. And now, their lives are defined by the same split reality: "before the earthquake" and "after the earthquake."

Sitting in their cramped office, the brothers tell the story of most Haitian medical providers and hospitals. Since the earthquake, Haiti has been awash with doctors from all over the world providing the kind of top-notch care rarely experienced in this chronically poor country. It has been a gift of epic proportions, the Bitars say, in a place burdened with disorganized health care, and high rates of HIV and tuberculosis.

But as the immediate crisis starts to wane, more and more patients with maladies unrelated to the earthquake are turning to international health-care teams led by the World Health Organization, raising concerns about Haiti's ability to care for its own once the relief teams pull out and need for rehabilitation and long-term care grows.

The Bitars ask what appears to be a simple question: How can the country's medical structure be rebuilt when hundreds of humanitarian teams are still providing health care for free? The surgeons say they have no income -- not from the poor and not from their private practice. For one, 700,000 people are now homeless with no access to funds. For another, the hospitals, the Bitars and others say, are finding it hard to compete with the visitors. With no end in sight, some of the nation's doctors have already left, and others are considering leaving.

"We have not been able to make payroll for two months," Jerry Bitar said.

Marlon added: "I am very worried that many of our good doctors will leave. The humanitarian hospitals, they don't ask for any money. Yesterday, I went to one and saw two of my private-paying patients getting treatment there."

Indisputably, international organizations are carrying the Haitian health-care system today -- and will continue into the indefinite future. Many Haitian health-care providers were among the 230,000 killed in the earthquake, and others have not shown up for work, dealing with their own losses. The nursing school at the University Hospital collapsed during exams and killed essentially an entire first-year class of nursing students.

"It is a very difficult situation," said Thomas D. Kirsch, a professor at the Johns Hopkins medical school and an expert in developing-world health issues who was recently in Haiti. "If these organizations pulled out, the system would be worse than ever, and as long as there is free care available, that's where the Haitians will go and the Haitian doctors will have no business. . . . There must be a well-planned transition period to subsidize the Haitian health-care system, have [nongovernmental organizations] work directly with Haitian providers, and to train sufficient providers and nurses to be able to meet the population's needs."

Nyka Alexander, a spokeswoman for the World Heath Organization, said that "the international community working in health will not leave before a system is in place, and this is precisely what we are working on . . . to build an accessible system better than what was here before the earthquake." One part of the plan, she said, was suggested by locals: Build mobile clinics so people don't have to rely on emergency rooms.

"It's going to require strong leadership from the Ministry of Health to develop new policies, training and better pay," said Dana Van Alphen, a doctor handling disaster management in Haiti with the Pan American Health Organization.

The Bitars concede that they are overwhelmed with the new needs thrust upon them, and that current resources are not enough to meet demands.

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