Monday, January 23, 2012

Implementation of basic oral health care delivery systems in Haiti (Deux)

Cap Haitien, Haiti

Today we packed our supplies and equipment and headed to the clinic in the Justinian University Hospital about 10 blocks away.  The Justinian is the main public hospital in town with 250 beds serving almost a million people in northern Haiti. 
At the oral maxillo-facial surgery/dental clinic in the Justinian, my site mentor had set up an educational day session where we train local Haitian dentists and nurses in restorative techniques practiced in the States.  We dragged in box after box of materials, equipment, and supplies and eagerly dove into seeing the waiting room full of patients.  It didn't take long for the day to take a downward turn.  Let me explain.  Modern dentistry in America is a smorgasbord of products, with every procedure requiring specific instruments and materials.  You want a simple clear filling?  Of course, just go get the high speed drill, low speed drill, 330 bur, 245 bur, #6 round bur, 2% lidocaine with 1:100,000 epinephrine, 20% topical benzocaine, local anesthetic syringe, 27 and 30 gauge needles, cotton tips, 2x2 gauze, patient bibs, high speed suction, low speed suction, air/water syringe, mirror, explorer, endo ice, barrier tape, Fuji liner/base, mixing spatula, mixing pad, curing light, phosphoric acid etch, Optibond Solo, applicator tip, A3 Herculite composite, plastic instrument, Mylar strip, wedge, composite finishing burs both flame shape and football, college pliers... and yes, this is the basic setup for one restoration.  All these materials need to be laid out and prepared before the actual procedure due to the setting times of the materials resulting in a race against the clock.  Imagine the flurry of activity in the small, two-chaired room as we realized mid-treatment that we were lacking essential instruments and materials in the very specific procedures we were performing.  This was complicated by the malfunction of the overhead lights, compressor breakdowns, and a flood of constantly leaking water, which resulted in moisture leakage in restorations requiring dry fields.  A primitive "sterilization room" was set up across the hall, but mostly we wiped down handpieces et al with extra masks and a dollop of Purell.  In addition, most of the restorations we performed were heroic efforts to save what remaining structure was left in symptomatic patients who essentially needed more complicated procedures but could not due to time, supply/equipment limitation, and finances.
Facial trauma also fell under the auspices of the clinic, as seen in the photo below of a woman 4 days s/p motorcycle accident.  The local dentist explained to us that in the past 3 years, motorcycle usage and thus accidents had increased exponentially in Cap Haitien.  For this patient with a through-and-through philtrum/upper lip and infraorbital laceration, only one interrupted 1-0 nylon suture was available to close the lac.  Having just come from rotation at MGH oral maxillo-facial surgery, it was a different world to say the least.
In addition to the mechanical complications, the dynamic between our team and the local health care providers had to be handled with utmost delicacy, as we were careful to emphasize a symbiotic learning relationship instead of imposing a foreign "know-how" attitude.  At the end of the day, all the biohazard waste was dumped outside next to the steps of the clinic.  Our team looked at each other, defeated.
We had a long discussion with our site mentor, who revealed that this day was constructed to reveal the gaps in our approach to public health, specifically when we apply our American protocols to a situation that cannot be translated in Haiti.  Despite our best intentions, a 30-piece setup with reliance on dependable water, electricity, high technology, and sterile fields are not completely reasonable nor at times appropriate.  Sometimes it is necessary to forgo our strict tutelage and employ a more practical philosophy.  It is the unspoken rule in Haitian healthcare- rules are meant to be broken.
This was further emphasized during dinner with a local urologist, who told us stories of water leaking from the ceiling into his sterile field in his ORs, making molds for amputees' leg prosthesis from 2-liter coke bottles, and chickens running through the surgical wards of the hospital.  He told us how after 20 years of work in Haiti, he leaves every trip questioning his contribution and purpose.  It is after days like this and conversations like this that make me understand Haiti and the draw of Haiti more- that this piece of land with its complicated history, politics, and tensions makes it into the Rubik's cube of the public health universe.

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