A loud bang on the hospital door leading to the ambulance bay announced the first trauma case the morning of October 10. A patient had just arrived at University Hospital’s emergency department in Mirebalais, Haiti. The victim was one among nearly 50 people injured when an overloaded passenger truck flipped on a hairpin curve along Route Nationale. Within minutes, dozens more victims flowed into the facility, transported by private vehicles that had happened upon the scene. Hospital staff quickly triaged patients and settled them into emergency department beds. When those filled, they found space on the floor and in the neighboring hallway.
The scene was “controlled chaos,” said Alan Simmons, the medical informatics implementation manager who lent a hand that morning. Chief Nursing Officer Marc Julmisse stood atop the nurse’s station with a bullhorn shouting instructions to medical personnel. Regan Marsh, a co-director of emergency services, dashed from one victim to the next, giving advice to staff in Creole, French, and English. Administrative personnel from across the hospital rushed in to help, fetching equipment and supplies as needed. Facilities staff brought in fans to keep the beehive cool. And security officers blocked curious onlookers while keeping the entrances clear. Inside an hour, all the patients had been sent to surgery suites or accommodated into various wards.
Marsh and Shada Rouhani, co-director of the emergency department, reflected on the success in an email sent that afternoon to hospital staff. “While a tragic event like this shakes everyone involved, it has also revealed the power of the hospital community,” they wrote. “Thank you all for your assistance and support. It is a privilege to work with you each day.”
Had University Hospital not existed, patients would have had to travel several hours over treacherous roads to the towns of St. Marc or Hinche to receive care. Some surely would have died en route. The horrific accident was a test that proved the hospital’s mettle and signaled how far medical and administrative staff have come since the day the hospital’s doors opened in March 2013—two years ago this week.
The 205,000-square foot, 300-bed facility was a boon for the region and the country following the January 12, 2010, earthquake, which devastated Haiti’s largest public teaching hospital, l’Université d’Etat d’Haïti, nursing school, l’Ecole Nationale des Infirmières, and other critical medical infrastructure in Port-au-Prince. Partners In Health and its sister organization, Zanmi Lasante, had been planning to build a small community hospital at the site, but up-scaled those plans following the natural disaster at the request of Haiti’s Ministry of Health.
Thanks to generous donations, the hospital was designed, built, and fully outfitted within a $17 million budget. It’s now the nation’s largest public sector hospital, which provides care to 725 patients on an average weekday.
Meeting growing demand
Since 2013, University Hospital has steadily expanded its services and now offers primary and dental care, mental health services, pediatrics, maternal and women’s health, emergency medicine, oncology, surgery, and HIV care. Patients are taking advantage of their options.
Hospital visits grew exponentially from 232 in the first month of operation to 15,822 in January 2015, according to PIH’s Monitoring, Evaluation and Quality (MEQ) team. The vast majority of patients schedule general consultations, but a large proportion come for specialty care in the women’s health, pediatrics, maternal, and surgical departments.
Maxi Raymonville, the hospital’s medical director, says one of the biggest rewards for him is “bringing access to the most vulnerable” patients in Haiti, such as women who die needlessly during pregnancy or childbirth. “I’m really proud as an OB-GYN to see the big differences in Haiti in cutting maternal mortality.”
The steady stream of patients at University Hospital relieves some of the pressure placed on public hospitals in Port-au-Prince an hour away. Roughly 40 percent of patients come from communities immediately surrounding Mirebalais, yet a surprising number travel longer distances to access the hospital’s free care. About 30 percent come from St. Marc, Port-au-Prince, and its surrounding suburbs.
Teaching the next generation
In Haiti, there are currently 25 doctors for every 100,000 people, compared to the U.S. where there are nearly 300 doctors for every 100,000 people, according to the World Health Organization. A major part of University Hospital’s mission is to help train the next generation of Haiti’s health professionals to improve that ratio, especially when it comes to medical specialization.
Hospital staff, in collaboration with l’Université d’Etat d’Haïti, l’Ecole Nationale des Infirmières, and other international partners, developed academic programs to train future nurses, doctors, and hospital support staff. So far, at least 420 medical professionals—including doctors, residents, and nurses—have received more than 10,600 hours of training.
Dr. Kerling Israel, director of medical education for PIH/ZL, has been the one leading that charge. She helped launch the first round of residencies two years ago in internal medicine, surgery, and pediatrics, and created three more last year in obstetrics/gynecology, anesthesiology for nurses, and emergency medicine—the first such residency in the country. These 48 residents have completed more than 2,800 hours of training in their respective specialties over the past two years.
The application process is highly competitive, Israel says, adding that 260 recent medical graduates applied for the 34 spots in last year’s class alone. The high number indicates that opportunities to specialize are still scarce in Haiti.
“We have a lot of Haitians, both teachers and students, who’ve gone to the U.S., Canada, or the Dominican Republic because they couldn’t find a place to get proper training,” says Pierre Paul, PIH’s program director of talent management and leadership development. “In my class in medical school in Haiti, more than 80 percent is now working in the U.S. or Canada. … That’s still true after the earthquake. That increased the magnitude and speed with which people are leaving.”
University Hospital’s residency program, Paul says, “has been a game-changer,” especially for young physicians contemplating whether they can find work in Haiti and practice with a standard of excellence.
Ideally, University Hospital residents will not only transform the health care system, but “stay in Haiti in the public sector, and staff and run the teaching hospitals opening across the country,” says Michelle Morse, PIH’s deputy medical director for Haiti.
Nurse training is an equal and important need in the health care system. Julmisse has seen her staff grow from 40 registered nurses two years ago to just under 300 nurses, nursing aids, midwives, sterilization technicians, and nurse anesthetists. Through a combination of bedside training, nursing rounds, and courses toward specialty certification, she has seen employees grow in confidence and competence. They talk to her about the types of specialties they would someday like to develop. And many have assumed leadership roles within their respective teams.
“Compared to questions asked before, what they ask today is deeper,” Julmisse says. “They’re faster, they’re doing a lot more critical thinking. They’re not afraid to advocate. It makes me proud.”
More than a medical mission
University Hospital has undoubtedly improved access to quality health care in the suburban and rural regions surrounding Mirebalais. And its impact reaches beyond the medical. For every $1 invested in the hospital annually, $1.82 is pushed out into the larger Haitian economy, according to MEQ, which arrived at the figure in partnership with Haitian and U.S. researchers.
Although measuring this impact is complex, the idea is simple. Hospital employees use their salaries to pay for housing, education, transportation, and food for themselves and their loved ones. They buy goods at local markets from farmers and shopkeepers, who in turn use those additional funds to invest in their businesses or improve their family’s standard of living.
Success comes in many forms at University Hospital. More patients receive preventive or life-saving care; more doctors and nurses obtain advanced training; and more money flows into a community with few economic options. And there’s something else that may be harder to measure: trust. It surfaces in the choices community members make when they pick Mirebalais as the place to go in an emergency, just as they did that day back in October.