HAVANA TIMES, April 22 — Dr. Patrick Dely gives Connery Gorry of medicc.org an on the ground look at the situation facing Haitian doctors from his perspective of having graduated at Cuba’s Latin American School of Medicine (ELAM) and the challenges of inserting himself into a highly deficient heath care system in his country that is also amid recovery from the devastating January 12 earthquake.
INTERVIEW WITH DR. PATRICK DELY: PART II
By Conner Gorry in Port-au-Prince, Haiti
Dr Patrick Dely spent his early childhood in St Michel L´Attalaye, a town in the central department of Artibonite where the environment was nearly exhausted and educational opportunities limited (to say the least). He attended Haitian public schools – where up to 150 students crowd into a classroom, oftentimes without a teacher – and always dreamed of becoming a doctor.
However, until a friend alerted him to the possibility of a scholarship to study medicine in Cuba, his future practicing medicine remained just that: a dream. Over ten years later, Dr Dely is a family doctor who was a few weeks short of obtaining his second specialty in epidemiology in Cuba when his country was devastated by the January earthquake.
In Part II of this interview, Dr Dely talks with me in Port-au-Prince about difficulties facing the Haitian public health system, what challenges that system presents to Haitian doctors trained in Cuba, and his future plans for his hometown and beyond. To learn more about this remarkable young man see Part 1 of this interview.
The Latin American Medical School (ELAM) trains doctors for public service, to work in underserved areas. In your view, what are some of the difficulties faced by these doctors when they return to Haiti?
Haiti is extraordinarily complex, in every sense, and there are many factors impeding the insertion of these doctors into the public health system. First, there’s the question of political will. We began studying in Cuba over ten years ago, in 1999. But during the six years that we were studying, there was no structure or strategic plan for how to absorb and place these doctors in the Haitian public health system. No one was asking: ‘How are we going to receive these doctors?’ ‘How are we going to distribute them in the health system?’ So we faced a bitter and troubling situation when we arrived.
Then there’s the economic problem. The government just doesn’t have the budget to employ all these graduates. [Since the first commencement in 2005, the ELAM has graduated 550 Haitian doctors]. For those it does employ, the salary is so low, doctors can’t make ends meet, and even their most basic needs can’t be met on this salary. Remember, also, that Haiti is a capitalist country and this combination has created a vicious cycle: A doctor, although he or she works in the public health system, has their private practice on the side to earn a living and really the state has no recourse because they don’t provide a living wage.
So doctors hold down two jobs essentially?
Here’s how it plays out: let’s say there’s a surgeon who is the director of a public hospital. As director of that hospital, the surgeon earns $US600 a month. It’s very difficult to live on 600 dollars in Haiti, so this hospital director maintains a private clinic. He might work an hour or two at the hospital and then he goes to his private clinic. At his clinic, he charges $20, $30, $50 to whoever walks in the door for a consultation. This is how he makes a living. Meanwhile, the services in his hospital suffer or don’t function at all because he’s not there.
That’s how it plays out for the hospital director. How does it play out for patients?
In the public hospitals, the patient has to buy everything – cotton, syringes – all the supplies needed for their treatment. And there are few doctors, so even those patients who have money to buy the supplies might wait five hours for the doctor or maybe the doctor doesn’t show up that day. So most people prefer to scrape together the money to go to a private clinic. Even if they have to sell something, even if they can only go once and will have no follow up, they prefer to go to a private clinic. If the patient is poor, too bad. They have to find some money, somehow, to pay for care. Until the patient demonstrates that they have the money to pay, the doctor won’t even touch them. If there isn’t someone to assume the payment for them, they go without treatment, suffer, and may even die.
Returning to our hypothetical surgeon and hospital director, his way of life depends on what he charges his patients, which means this doctor sees his patients as clients. Essentially, in Haiti, health and medicine isn’t seen as health and medicine, but has been converted into a business. The state, without the ability to budget for a health system, has entered this vicious cycle.
How do graduates of the Latin American Medical School reconcile this conflict between private and public care, given that the school is designed to train doctors for public service?
The ELAM trains doctors to treat patients. When a person arrives bleeding, the ELAM doctor isn’t going to ask to see their ATM card before providing treatment. They may hope for a little something afterwards, but they know they probably won’t get anything since these are poor people with nothing to give! They try to help out the neediest cases when they can, but still, many resolve it exactly how I’m describing it to you. They work with a clear conscience in a public hospital and in their free time they work in a private clinic or hold private consultations. This is the vicious cycle I was talking about. It’s very difficult.
Over 500 Haitian doctors have graduated from the ELAM so far, with around 100 more graduating every year. What impact are these new doctors having on this private/public care dichotomy?
It’s problematic. Let’s take for example a Haitian gynecologist who is having car trouble. She’s waiting for a patient needing a cesarean section to resolve the problem with her car. It is that calculated: this doctor is waiting for a C-section patient to walk in the door and pay to fix her car. And I arrive from Cuba, extraordinarily enthusiastic to work anywhere I’m needed, to go to the most remote corner and serve in whatever conditions. This means I’m taking money directly from the pocket of this gynecologist. So we are seen as a threat and that’s the first problem.
The second problem is that practicing medicine has always been viewed in Haiti as a luxury, something elite. Something noble and elite – not just anyone can be a doctor. Then all of a sudden there are these masses of humble young people returning as doctors, proving they can be doctors too. And this has effects here like in any market economy: if something is in short supply but high demand, suppliers set the price. But once there is a larger supply, (in this case doctors), it shifts the dynamic. We’re a threat to that dynamic.
ELAM doctors are trained entirely in Spanish. In your experience, is language an issue for you and your colleagues once you return to Haiti?
It’s really important to find books in French, if not to study, at least to familiarize yourself with the language. I learned terminology in Cuba that I didn’t know before, so I can explain things to you in Spanish but I have no idea what words to use in French or Creole!
And another thing – you can’t even write a patient’s clinical history in Creole here. It must be in French. Even in the countryside. Everyone here speaks Creole, but when you have to write something, it has got to be in French. During patient consultations for example, you ask questions in Creole, but record the responses in French. And when you have to refer someone to the hospital, you do it in French. If you sent someone to a hospital with a referral in Creole, the receiving doctor would say: who is this doctor who is writing in Creole?!
Creole is an official language here but isn’t accepted as such. I was on the bus one day and a woman said: ´I’m not going to that doctor anymore. He speaks to me in Creole!´ She was judging him on his language, saying – this doctor doesn’t know anything, he speaks Creole. She was actually offended. It’s very, very difficult. But little by little we’re going to break through these prejudices and myths.
How do you see your future?
My future? My future isn’t to have a big house or a new car. You know what I did before studying medicine, when I was a professor and received my first paychecks? I went and bought a car. I had been walking to class and I saw my students arriving in cars, which gave me a huge complex, so I went and bought a used car. But today, I’m a doctor, I’ve nearly attained my second specialty and I can walk to meet with the President, I can walk to meet the director of the UN. It means nothing to me to have a car! It’s a tool, sure, but this isn’t what I consider a future.
My future is to see my country transformed, a different country, where Haitians feel happy and proud to be in their country. Where they don’t need to emigrate, where Haitian children have access to education and our youth has access to sports and recreation. I see myself working to make this Haiti a reality. My future is to work towards change.
That future also involves your project in your hometown of St Michel. Tell me a little about that.
I was born in St Michel, but I had to leave for the capital when I was eight years old because there was no middle or high school. So what options does a young person from St Michel have once they finish primary school? They have to work in the fields or emigrate. Sometimes it makes me cry to go back there…I used to dive from rocks in the river, but now you can cross that river without getting your pants wet. They’ve cut so many trees, the rivers are dry, there’s no wild game anymore, and it’s so deforested. This is a region where there was never hunger – there were a lot of mangoes, avocadoes, people grew corn. But people have abandoned agriculture because agriculture doesn’t provide a living. So what do they do? Kids of 10 or 11 go to Santo Domingo to work, to cut cane, and come back with nothing. This always alarmed me and is painful still.
So I started thinking. What can I do? How can I help my people? I’ve got the education, now what about the vision? And I started envisioning a comprehensive project where a poor child who doesn’t have the opportunity for even a grade school education can enroll as a small child and leave as a skilled, useful member of society. A place where a child receives a primary, secondary and technical education based on love of country and work. This child can study music for example, receiving training that could transform him into a famous musician. Or maybe the child will opt for alternative agriculture, using different techniques than his father used, learning and developing techniques to make that same plot flourish and profitable. Or we’ll teach this kid to be a carpenter, plumber or electrician – even though in the St Michel area there are places that still don’t have electricity! – But we have to think of a better future.
With such a comprehensive education, with solid technical skills, this child can graduate as a plumber and I don’t have to worry that he or she will emigrate to Santo Domingo. Or maybe that child will become a carpenter and even though the government can’t assure him a job, he can open a workshop in his yard and work and earn money to support his family, and lead a dignified life.
Meanwhile, this project will guarantee this child’s food in a community garden and there will be a hospital to attend to the sick, so they don’t have to leave St Michel and travel long distances looking for health care. Right now there’s a health post in St Michel with three doctors. One is the director and the other two are doing their required year of social service. After that they leave. We’re talking three doctors and 10 nurses for 140,000 people. But these are the official statistics; they don’t reflect the reality of absenteeism and the like.
What stage is the project in now?
Well, I wasn’t really sure how to get started and it took me a while since I didn’t have anything… but I was convinced I had to lead by example. So I did what I would like other Haitians to do: start with what you have, even if what you have is very little. My father had this little piece of land and he said: ‘it’s all I’ve got, but if you’re serious and are going to do something useful, I’ll give it to you.’ So I decided to start the project with the school, with one class and one teacher, on that land. That was in 2007; we started with 30 students. Today we have four times that. When I move up there, I think I’m going to be one of the professors – at least when I’m not working as one of the doctors!
Is that your dream? To work in St Michel and grow this project?
My dream is that these kids receive some of the best education in the country, so I can enter St Michel one day and see a child playing an instrument or creating something great. To see those children, happy and learning, that’s the St Michel project. And beyond St Michel, Haiti. With the desire, faith, and perseverance to succeed I believe we can make it happen. If I can see this throughout my whole country, I will be the happiest man alive.
See related article from Trinidad and Tobago.