Forget Zika, Haiti has bigger problems — a doctor strike

July 02--The public morgue is closed. The beds are empty. With Haiti's biggest public hospital on strike, the once crowded courtyards of desperate patients have become trash-strewn ghost towns populated only by soul-searching medical students.

"It's the biggest blow they could have dealt us," said Magalie Laurent, 48, who had to suffer through a two-hour drive north with both legs broken so she could get to the only functioning emergency room available for Haitians who can't afford private healthcare.

"Hospitals are not supposed to shut down," she said, fighting back the pain as she huddled in a wheelchair at the University Hospital of Mirebalais, a public-private hospital that is being overwhelmed by the crisis. "You have protests over food, not over hospitals."

Poor Haitians like Laurent, already struggling to survive a cholera epidemic, rising malnutrition, a Zika virus outbreak and a political crisis that has left the country with a dysfunctional government, now have one more malady to add -- a dire public health crisis. A perfect storm of striking medical residents, missing doctors and a lack of money has virtually paralyzed an already weak healthcare system, and no one seems to be in a hurry to fix it, critics say.

"All of the public hospitals around the country aren't functioning and no one is saying anything. Everyone is walking around like it's no big deal," said Dr. Maurice Fils Mainville, executive director of the State University of Haiti (HUEH) Hospital, or the general hospital, as the country's key medical facility is more commonly known.

"The population believes in the hospital," Mainville said of the teaching facility, which has stopped admitting patients along with about seven other public hospitals. "Traditionally, culturally, they know that this is where all of the specialists are."

But there haven't been any specialists, at least not since resident doctors revolted on March 28 after accusing the general hospital's new administrator of slapping one of their peers in an argument over a delayed test for a patient.

The strike widened after a petition drive and Facebook postings by residents and interns complaining about paltry pay and calling their working conditions life-threatening. Twelve more government-run hospitals shut their doors. Only few are partly functioning today.

"This rotting system is either going to totally collapse or it's going to have to improve," said Dr. Rishkord Juin, 26, one of the strike's leaders. "We don't want the hospital to turn into a morgue, and if we're going to work there, it has to be under good conditions."

So far, negotiations have proven fruitless. Interim President Jocelerme Privert, whose wife is a doctor, has demanded that the resident doctors return to work. They are not public employees and have abandoned their training, he said.

"I am in favor of a collaborative solution," Privert said in an interview, "but the state will not negotiate with a knife to its throat."

On Thursday, the palace tabled a revised budget in the Haitian Parliament. It included a proposed increase in health spending of 9.6 percent from 4.7 percent, and a salary increase for public health workers including residents currently earning the equivalent of $120 a month, according to Ministry of Health Executive Director Gabriel Timothé.

Timothé, who did not respond to the Miami Herald's interview request, announced that the government will partially reopen the capital's Isaïe Jeanty-Léon Audain of Chancerelles, a maternity hospital, with prenatal and gynecological services only -- a move resident doctors dismissed as "symbolic."

Residents say it will take more than a salary increase to get them back into the emergency rooms. Still, they note, they are demanding double the $222 to $270 a month the government is currently proposing.

In Haiti, the crisis has raised questions about the ethics of the doctors who are striking as well as about the role of foreign aid in the country's weak health system and what kind of health system the country can and should afford.

It has also raised another daunting question: Where are the poorest of the poor going for medical care?

"If you're sick right now, and it was left up to the state, you would die," said Roberson YouYou, 35, who was rushed to Doctors Without Borders/Medcins Sans Frontier (MSF) trauma hospital in Tabarre after being hit by a car.

YouYou was attempting to cross a street. That street was within walking distance of the general hospital. But it was closed.

"Even if they had taken me there," he said, "I wouldn't have found decent medical care."

Conditions at the public hospitals have been deteriorating for years. While treatment is subsidized, patients are forced to buy the basics, including gloves and syringes. Machines are often broken, operating rooms are filthy and power outages are common even during surgery, doctors say.

"Imagine you need to operate on a patient and there is no water or anesthesia. It's revolting. You are trying to give someone life and it's in these kinds of difficult conditions," said Dr. Elizabeth Simon, 29, an anesthesiology resident.

Simon's younger brother, James, an intern in his last year of medical school, said the conditions are no better at Justinien University Hospital in Haiti's second largest city, Cap-Haitien. In October, he said, he saw a woman die at the 250-bed government-run facility because she couldn't afford $16 to purchase oxygen.

"The will was there. But I couldn't do anything for her in that moment because there was no oxygen," he said. "Everyone is in the same dynamic, the incapacity of the system to meet everyone's needs."

This is not the first time public hospitals here have been crippled by disgruntled workers. But it is the first time that a strike has endured this long -- more than three months now -- and spread to so many government hospitals. While private providers say they haven't been affected by the shutdown, nongovernmental organizations such as MSF and Boston-based Partners In Health/Zanmi Lasante, which operates the Mirebalais teaching hospital, say they are being overwhelmed demand.

"We have an enormous problem in referring pediatric patients, children," said MSF's Chief of Mission Azaad Alessandro Alocco. "The only place we could send children before was the general hospital. Today we don't know where."

Virginie Thys, who runs MSF's 120-bed trauma hospital in Tabarre near the international airport in the capital, said hospitalized patients are staying longer and they've had to add more beds. She's even had to place men and women in the same room for lack of space. But despite MSF's life-saving reputation for trauma, there are still some patients it cannot treat at any of its specialized facilities.

"Imagine someone coming here with a heart attack," Alocco said. "We don't have this specialization here."

Two hours north, where they do have the know-how, the 250-bed University Hospital of Mirebalais' is being overwhelmed by 1,500 patients a day, executive director Dr. Maxi Raymonville said.

"We have to [treat] people in chairs because there is no room," Partners In Health/Zanmi Lasante co-executive director Dr. Fernet Léandre said late last month, as he walked through the emergency room where all 17 chairs and 21 beds were occupied.

Léandre, who attended medical school in Haiti, said residents' complaints aren't new. A lack of materials was a problem, he said, in the 1990s during his internship at the general hospital. Tired of watching too many babies die during his rotation at the pediatric ward, he did not return after his government-required year of service was over.

Mirebalais, a public teaching hospital built and operated with money raised after Haiti's devastating Jan. 12, 2010 earthquake, has remained open. Its resident doctors, like MSF's, make double what the government-run hospital doctors earn. And they've been inundated with poor patients who are have been referred by other hospitals that couldn't handle their complicated cases.

"MSF said my case was too grave for them," said Eel Desmond, 63, who camped out overnight outside the hospital's packed emergency room along with hundreds of others for a spot on the waiting list after taking a three-hour bus ride from Port-au-Prince. He had a swollen leg, bone fracture and possible head injury after a nasty fall.

A doctor searched for an available bed for him but there weren't any. He was given a wheelchair instead, near Laurent with her broken legs. Across from them: a man with a open fracture waiting to go into surgery and, off to the side, a preemie swaddled in a pink blanket, born after 34 weeks. She was one of 10 babies waiting in the ER because the 18 beds in the neonatal unit were full, as were the 38 beds in pediatrics. An exasperated doctor, looking for babies healthy enough to discharge to make way for others, found none.

"It's really hard for them," Raymonville said. Doctors are trying to "create some space, but it's not easy."

Dr. Ronald LaRoche, a Haitian-trained doctor with degrees from Yale and Harvard, said the healthcare crisis has been caused by three things: medical students unhappy with their pay and lack of supplies; aid from foreign countries spent on facilities and specific diseases but not primary care; and the overall lack of an integrated health policy.

"I agree with them, they have a right to protest and I support them," LaRoche, the president of the Association of Private Hospitals in Haiti and founder of a group of private hospitals and clinics, said about the resident doctors. What he cannot accept, however, are the missing state-paid physicians who are supposed to be caring for patients at the public hospitals. They, too, have been absent during the strike.

"Where are they?" he asked incredulously. "Ninety percent of the budget of the ministry of health is for paying doctors."

The problems date back beyond the current provisional government, LaRoche and others here say. Successive governments and foreign donors have long ignored the daunting main issue of making healthcare sustainable in Haiti beyond donor support, critics say, instead picking and choosing what they want to finance.

Instead of financing primary care, for instance, they have focused instead on bricks and mortar. Canada recently shelled out $30 million for a new government hospital in the city of Gonaives that observers say was "a white elephant" before the strike shut down its operations. The United States and France are financing a new $83 million general hospital -- but the government has yet to figure out how it will pay for its upkeep and operating costs.

"We should start funding our own healthcare system," said LaRoche, an advocate of universal health care coverage for Haitians similar to Obamacare. "Those who can pay for an insurance card should pay for it and those who cannot, we have the government, with the taxes and assistance they are receiving from the international community, buy them an insurance card."

PIHs Chief Medical Officer Dr. Joia Mukherjee says there is a lack of will by the Haitian government to make health a priority but nongovernmental organizations (NGOs) are not completely absolved in the mess. Their fragmented efforts have sometimes worsened the problems.

"There's NGO money in this country that is doing nothing to help this country," she said.

NGOs, though, say they have to focus on the areas where there is need.

"In some some places people will have to make the harder choices, 'I pay for health' or 'I pay for food,' " MSF's Alocco said. "We know that there is this challenge."

Even before the strike, the health system was overwhelmed. That's why MSF recently decided it would remain in Haiti another seven to 10 years, Alocco said. But there is a limit to what the medical organization can do, he said.

Back at the general hospital, a handwritten sign from the striking residents in the staircase leading up to Mainville's office reads in Creole, "Hey, administrators! The wind has turned."

Outside in the echoing yards, medical students pace with books in hand, not sure how to continue their state-paid education. They defend the resident doctors' cause, though it throws their own careers into question.

"They are not doing this for personal gain, they are doing this to change the lives of the population," said Jhon Clifton, a student.

He asks how to explain a patient who dies in the hospital for lack of a common medicine.

"No one should accept to work under these kinds of conditions," said Clifton. "The situation is truly chaotic."

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