JÉRÉMIE, HAITI – Natache Mizene, 29, lies in a bed at Hôpital Saint-Antoine de Jérémie, the only state hospital for the Grand'Anse department. She is wearing a green, floral gown, and her whole body is swollen.
Her doctor has diagnosed her with kidney failure.
“I am diabetic, I have difficulty breathing, and I have hypertension,” says Mizene, an accounting student. “My doctor says I suffer from renal insufficiency.”
But she can’t get the treatment she needs at St. Antoine Hospital, located in Jérémie, the capital of the Grand'Anse department in southwestern Haiti.
“I was in the hospital for three months already when they sent me to another place because they could not do anything for me,” she says.
Frantz Alexis, 25, an intern at St. Antoine Hospital, confirms that the hospital can’t provide Mizene with the treatment she needs.
“Mizene should have an ionogram, a special type of blood test,” Alexis says. “But unfortunately, we do not have the equipment for that here at the hospital.”
Alexis is a third-year student at École d’Infirmières Notre Dame du Perpétuel Secours, a local nursing school.
“What makes her body swollen like that is that she has difficulty urinating, so all the salt stays in her body,” he says.
They have prescribed medication for Mizene that makes patients urinate, but it is not working, he says.
“She should see a nephrologist to look at her kidney, but unfortunately, we do not have a nephrologist here,” he says. “She needs to go to Port-au-Prince for that. In her case, there is nothing we can do for her here.”
Mizene says the hospital staff sent her to Port-au-Prince, the capital, to obtain care. But patients are responsible for paying for all their own costs, and she couldn’t afford to continue treatment away from home.
“After two weeks, I was forced to return here because I do not have the money to go to another place,” Mizene says.
Patients of St. Antoine Hospital say they suffer physically and economically because they can’t obtain the care they need locally. Staff members attribute this to a lack of specialists and resources. The directors of the hospital and the Grand'Anse delegation of the Ministère de la Santé Publique et de la Population, Haiti’s public health and population ministry, cite some progress but acknowledge that significant change is still needed.
There are 45 public medical institutions, including small clinics and dispensaries, that serve the nearly 433,000 inhabitants in the Grand'Anse, says Dr. Jean Lionel Gerôme, director of the ministry’s Grand'Anse delegation in Jérémie. But St. Antoine Hospital is the only state hospital in the department.
Dr. Jean Marie Duvilaire, 65, a surgical physician, serves as the director of St. Antoine Hospital. He says the hospital, which was built in 1923, has grown along with the population.
But patients and staff say not all medical services are available at the hospital. This hurts patients’ health. It also affects them financially if they have to travel to obtain care at a different hospital or stay in the hospital until they can afford treatment elsewhere.
When patients need services that are not available at St. Antoine, the staff refers them to hospitals in other towns or departments. But transportation is another barrier, as roads are in bad shape.
Agnus Teodore Fils, a former St. Antoine patient, sits on a small bed in his home in beige shorts and no shirt. A belt hangs around his neck.
“I was shot in the right shoulder,” he says, visibly in pain. “They rushed me to the emergency room, where they removed the bullet. But there were additional small fractures.”
He says the hospital couldn’t provide the treatment he needed.
“They told me there was nothing they could do for me because they did not have an orthopedic doctor,” he says.
So they sent him to Les Cayes, a town in the Sud department. But the ambulance was out of commission.
“What was most difficult at my moment of suffering was that the hospital ambulance did not have tires or gas,” he says. “My family had to resolve these problems very quickly.”
His family paid for gas and tires in order to transport him to Les Cayes.
But not all families can afford to obtain treatment elsewhere.
Norman Benoit, who was born in December 2012, was in the hospital with his parents.
Dr. Nadege Nassice, 33, a pediatrician at the hospital, says that Norman has myelomeningocele, a birth defect in which the backbone and spinal canal fail to close before birth.
“There is nothing we can do for him here except put him on antibiotics so that the opening does not become infected,” she says. “We have to wait until the parents find the money to take him to a neonatal surgical specialist in Port-au-Prince.”
This shortage extends nationwide.
“There are only three or four neonatal surgical specialists in Haiti,” Nassice says.
Patients cannot obtain the care they need at St. Antoine Hospital because of a lack of doctors and resources.
Duvilaire took charge of the hospital in May 2010 after the former director died in 2009.
Services are available at the hospital, says Duvilaire, who is wearing black pants and a white T-shirt that reads “Jinekolog san Frontyè,” or Gynecologists Without Borders in Haitian Creole. But the problem is the lack of professionalism among the staff.
“The biggest problem we have at the hospital is that both doctors and nurses give the impression they do not care,” he says. “It is this unprofessional attitude that the patients criticize.”
He says he reprimands staff for unprofessional behavior, such as tardiness.
“For example, some morning, a patient comes in bleeding and is not being treated because the gynecologist has not come in yet,” he says. “When that happened, I needed to give him a reprimand.”
The staff is also too small to handle the volume of patients.
“We are lacking physicians at the hospital,” Duvilaire says. “We had one gynecologist for the whole hospital. Now, we have a second one.”
The hospital added a second gynecologist in 2012, but he has to leave every four or five months to see his family, who does not live in Jérémie.
“The hospital needs three other gynecologists because we need staffing stability,” Duvilaire says.
The hospital does not even have certain types of doctors.
“We do not have a single orthopedist,” Duvilaire says. “There was a time when I was the only doctor in the hospital. Can you imagine that? Now, we have two doctors on our permanent staff. Many of our patients have prostate problems, but we cannot do a lot for them because we do not have a pathologist.”
Sabin Saintil, 44, chief of nursing at St. Antoine Hospital, wears a blue shirt, beige pants and white tennis shoes. He attributes the staffing shortage to low salaries.
“I have worked at St. Antoine Hospital for 15 years,” he says, carrying a large, black bag. “In my opinion, the reason we have such a difficult time attracting doctors is the monthly salary they get.”
Orthopedists, for example, earn 25,000 gourdes ($600) per month at public health institutions, Duvilaire says. They are also few in numbers in Haiti.
“While the doctors in Port-au-Prince get the same low salary,” Saintil says, “they usually have private clinics on the side, which are profitable, and there are other side jobs they are able to do. Because there are no doctors here, I often take on the role of a doctor.”
There are not many doctors from Jérémie, and those from other areas generally like to stay in their own communities.
“They have to live in a city, which is not their city,” Saintil says. “It’s not easy.”
Duvilaire, who is from Abricots, another town in the district of Jérémie, says that the public health ministry asked him several times to take the director role before he finally accepted nine months later. He had wanted to stay and work to help his native community, where he had been directing a health center and serving as deputy mayor.
He has had equal trouble attracting other doctors to St. Antoine.
“Despite all my efforts to attract doctors, there really is no doctor who wants to come to St. Antoine,” he says.
Gerôme attributes this to the isolation of the Grand'Anse department.
“Due to the poor accessibility of the department of Grand'Anse, it is not easy to find specialists to work,” he says during a telephone interview while in Port-au-Prince.
Another issue is funding from the ministry, Duvilaire says.
“Since 2009, St. Antoine Hospital has not received a single gourde from MSPP,” he says, apart from employee salaries. “They only take responsibility for the salary of the employees. For the functioning of the hospital, we receive nothing.”
This hampers operations.
“We only have one generator at the hospital,” Duvilaire says, “and when that generator breaks down, we cannot do operations, do blood analysis and other things.”
Gerôme says the national budget allocates funding for public hospitals. The largest portion comes from the state and funds the salaries of staff, the purchase and maintenance of equipment, transportation and training.
International partners also provide additional financial support, he says, such as the U.S. President’s Emergency Plan for AIDS Relief, the Université de Nantes in France, Médecins du Monde in France and the International Training and Education Center for Health in the United States.
Duvilaire says he has tried to resolve the lack of supplies at the hospital by engaging with these partners.
“Where I feel I was successful was in getting material and equipment to the hospital,” he says. “The University of Nantes sent two containers of supplies for the hospital.”
Duvilaire says that when Dr. Florence Guillaume took over the public health ministry in 2011, St. Antoine received some additional aid. The hospital used a portion of the aid to pay additional staff.
“We were able to attract a dozen general practitioners and five extra nurses,” Duvilaire says. “It has helped us some.”
But Duvilaire says that before he leaves his position as director of the hospital, he would like to see significant change.
Gerôme says the state plans to reorganize the health care system to involve the community and other private sectors in health management and education. The state also plans to improve salaries and training of health care personnel, supervision of health care facilities, and the allocation and relocation of staff.
“A supervisory body was established at the departmental bureau level, with the intention of evaluating clients’ degree of satisfaction,” Gerôme says. “All elements were analyzed, including the reception, the length of the waiting period before meeting with care personnel, record-keeping, the confidentiality of personal records, the quality of diagnostics and treatment.”
It also analyzed physical and financial accessibility to services, the cost of medication, and the system of referrals and counterreferrals for patients requiring care unavailable in the department.
Gerôme says the ministry is also investigating allegations of past negligence within the ministry to identify those involved. It has organized training sessions and has formalized disciplinary action to avoid future negligence.
All interviews were translated from Haitian Creole, except the interview with Gerôme, which was translated from French.