Vincent DeGennaro

Linking surgical missions with training of developing-country surgeons.

S urgery is increasingly recognized as an integral part of global health efforts. The global burden of surgical disease, while significant, has largely been neglected because of the resources and training needed to implement sustainable programs. Surgical mission trips from resource-rich countries to developing countries have filled a small portion of the need, but large gaps still remain. The impact of surgical missions must be expanded from strictly delivering care to training local medical staff so that they can perform progressively more complex procedures and ultimately become self-sufficient. Visiting teams will continue to have an important role to play as educators, serving as specialists where none exist, and in pushing the envelope by adapting procedures for lowresource settings. In this issue, Patel et al describe a surgical mission trip to Haiti and the more interesting cases that they saw during their time there. They successfully make the case for using cooperation between university-based teams, nonprofit organizations, and governments to improve access to surgical care in Haiti and other developing countries. In order to provide universal access to surgical care on a larger scale, the global health and surgical communities will need to expand on the model. We have learned over 9 years of operating in Haiti that the most important aspect of a successful surgical mission is ensuring proper preoperative and postoperative care. Even the most experienced teams will have higher rates of unfavorable outcomes without a local team in place to evaluate and prepare patients prior to the trip, and to follow up with patients afterwards. Teaming up with local organizations that know the community ensures that resources for long-term care are in place, allows visiting teams to establish relationships with local physicians for training purposes, and serves as a consistent location to donate medical supplies or leave medical equipment for later use. The involvement of US residents and medical students may improve care in the developing country, but certainly improves care of the American patients they care for later in their careers. Resourcepoor settings force young doctors to hone their clinical instincts. More importantly, they learn how to practice with fewer resources, a skill that is often overlooked in the American training system. As the US struggles to finance high-resource medical care, doctors who are comfortable providing top quality care with fewer resources will become more valuable. To improve surgical care in the long run in countries like Haiti, academic surgical missions have an obligation to build capacity by training local healthcare professionals for the long-intervening periods when there are no visiting teams. Ultimately, training local staff is more cost-effective and more sustainable than importing American-based teams and can therefore have a greater impact. In the paper by Patel et al, patient 2 became infected and had to be transferred to the United States for definitive care of her advanced wounds. While their efforts are commendable, training local surgeons and providing the relatively few resources necessary to perform skin grafts might prevent similar cases from progressing as far in the future, reducing morbidity and the costs associated with transferring them to the US. Given the significant morbidity from burns and trauma and the dearth of experienced practitioners in Haiti, these could be the first fields in which to train local general surgeons in performing the basic procedures. In areas where specialists are not available in large numbers in Haiti such as plastic surgery, visiting surgeons can teach the basic skills needed to perform acute care and then can also operate on the more complex cases that remain outside the practice of local general surgeons. An example is burn care, where teaching local surgeons to perform fasciotomies and skin grafts will reduce the need for more complex procedures such as contracture releases. Local infrastructure improvements such as proper wound care and physical therapy will further augment the impact of surgical missions in the future. As academic surgical missions continue to do admirable work, we look forward to the time when their continued partnership with governments and nonprofit organizations makes them obsolete through building of native surgical capacity.

A national trauma capacity assessment of Haiti

BACKGROUND Trauma systems in high-income countries have been shown to reduce trauma-related morbidity and mortality; however, these systems are infrequently implemented in low- and middle-income countries. Haiti currently lacks a well-resourced and structured trauma system and in turn loses an estimated 800,000 y of healthy life to injuries annually. In the present study, we perform a nationwide trauma capacity assessment, and using the World Health Organizations Guidelines for Essential Trauma Care as a framework, we attempt to identify achievable steps that can be taken toward improving trauma care in Haiti. MATERIALS AND METHODS This cross-sectional study was performed at 12 facilities nationally using a survey tool assessing the areas of infrastructure, supplies and equipment, personnel and training, and procedural capabilities. Additionally, the total number of trauma cases presenting to each facility was tabulated from emergency room logbooks. RESULTS A total of six secondary and six tertiary facilities were surveyed. Secondary facilities received an average of 35 trauma cases per week, whereas tertiary facilities received an average of 65 cases per week. Survey results demonstrated a shortage of airway, breathing, and circulation equipment and supplies in both facility levels, particularly in emergency rooms. All facilities lacked access to essential surgical personnel and trauma training. CONCLUSIONS This study makes recommendations for improvements in trauma care in Haiti in the areas of infrastructure and administration, physical resources, and training and human resources. These recommendations represent feasible steps that can be taken toward the construction of a national trauma system in Haiti.

Building advanced surgical capacity at a hospital in Port-Au-Prince, Haiti

AbstractTo improve surgical capacity in developing countries, we must take a multifaceted approach that addresses all aspects of surgery in a hospital. Foreign non-governmental organizations with expertise and resources can play a role in helping to build surgical capacity in developing countries. Episodic surgical missions can contribute to reducing the burden of the disease, but must be coupled with training of local staff to assure capacity for the future. Lack of human resources and proper infrastructure should be addressed as part of the capacity-building process. Longitudinal educational programs improve the training of local staff over time. Scaling up from episodic surgical trips to building and maintaining fully functioning surgical capacity requires sustained and repeated interventions from a large group of stakeholders. Through partnerships with local government and nongovernmental organizations, each partner can amplify the effectiveness of the other to meet the challenges of complex surgical care in low-resource settings.

Hypertension prevalence: an examination of urban and rural Haiti

Abstract Background With the burden of disease shifting from communicable to non-communicable diseases, hypertension is rising as a major health concern in developing nations. Absence of data for surveillance and effect of non-communicable diseases restrict the ability of stakeholders to respond effectively. We aim to estimate the prevalence of hypertension in Haiti and analyse differences in hypertensive status among urban and rural location, age, and sex. Methods We reviewed medical charts at two Haitian clinics: one in the urban city of Port-au-Prince and one in the rural village of Marmont in the Central Plateau, and recorded age, sex, weight, blood pressure, location of patient (urban vs rural), and present treatments and which specific medications. Participants included all non-pregnant outpatients older than 25 years who visited the clinics at least once between Jan 1, 2011. and June 15, 2013. 1019 patients were included in the study; 520 from Port-au-Prince and 490 from Marmont. Findings The overall prevalence of hypertension was 34·4% (n=351, 95% CI 31·8–37·8); with a prevalence of 31·6% (n=167, 95% CI 27·6–35·3) in Port-au-Prince and a prevalence of 37·6% (n=184, 95% CI 34·5–40·9) and Marmont. Younger participants had lower rates of hypertension than did older participants. Patients aged 25–34 years had a hypertension prevalence of 12·0% (n=41), aged 35–44 years of 23·8% (n=51), aged 45–54 years of 46·9% (n=91), aged 55–64 years of 58·6% (n=65), and aged older than 65 years of 65·6% (n=103). No observable differences were noted between locations within the same age group. When sex was compared, 34·7% (n=227) of women and 34·0% (n=124) of men were hypertensive. Women in the rural location had a significantly higher prevalence (39·0%, n=122) of hypertension than women in the urban location (30·8%, n=105, p=0·028). Of 351 total hypertensive participants, only 54·1% (n=190) showed any evidence of being prescribed antihypertensives in their chart. Interpretation This study suggests that hypertension is a major health problem in Haiti. Interventions are needed to address the proper management of hypertensive patients through medications and follow-ups, particularly in rural hypertensive women. Further research needs to be done to confirm the increased hypertension prevalence in rural locations in Haiti and to explore the causes of the differing hypertension prevalence in populations by location and sex. Funding Global Health Scholar Award from the Department of Public Health Sciences at University of Miami.

Epidemiological, Clinical, and Histopathological Features of Breast Cancer in Haiti

Purpose Little is known about the epidemiology of breast cancer in developing countries, and Haiti has perhaps the least data of any country in the Western Hemisphere. Methods We conducted a retrospective review of all patients enrolled in an ongoing breast cancer treatment program in Port-au-Prince, Haiti, from July 1, 2013, through June 30, 2017. Data were drawn from each patients electronic medical record, paper chart, and biopsy results. Results The records of 525 women with breast cancer were reviewed for this study. The median age at presentation was 49 years (n = 507). The risk factors observed were as follows: postmenopausal, 50.8% (n = 354); nulliparity, 15.7% (n = 338); hormonal contraception use, 35.0% (n = 309); never breastfed, 20.6% (n = 316); family history of any cancer, 22.0% (n = 295); overweight, 51.5% (n = 332); and smoking, 5.0% (n = 338). Of all those staged, 83.9% (n = 447) of the patients presented with stage III/IV disease and more than half delayed care for > 12 months after first noticing a breast mass. For the subset of tumors for which estrogen receptor (ER; n = 245) and human epidermal growth factor receptor 2 (HER2; n = 179) status was available, the prevalence of ER-positive tumors was 51.8%, of HER2-positive tumors was 19.6%, and of triple-negative tumors was 38.5%. The 12-month mortality rate (n = 425) was 18.4% overall and 27.5% for those who presented with stage IV disease. Median survival was not reached. Conclusion Breast cancer in Haiti presents at an early age and advanced stage. Triple-negative, ER-negative, and high-grade tumors are common. Delays in seeking care and incomplete treatment likely contribute to the high mortality rate; however, as in black women in the United States, the distribution of tumor types may contribute to disparate outcomes.

Community-based diagnosis of non-communicable diseases and their risk factors in rural and urban Haiti: a cross-sectional prevalence study

Objective To estimate the prevalence of hypertension, diabetes and chronic kidney disease and their risk factors in a rural and urban region of Haiti. Setting and participants Community health workers enumerated 2648 households (909 rural and 1739 urban) via a multistage cluster random sampling method from July 2015 to May 2016, completed 705 rural and 1419 urban assessments for adults aged 25–65 years. Outcome measures We performed a WHO STEPS based questionnaire, measured two blood pressure values, weight, height, abdominal circumference and point of care test finger stick blood sample for haemoglobin A1c, creatinine and cholesterol (total, high density lipoprotein (HDL) and triglycerides). Results After adjusting for age and sex, the overall prevalence rates of hypertension, diabetes and chronic kidney disease were 15.6% (±2.93%), 19.7% (±1.57%) and 12.3% (±2.72%), respectively. Of the three non-communicable diseases (NCDs), only diabetes showed a significant difference between rural and urban sites (p=0.000), with the rural site (23.1%) having a higher prevalence than the urban site (16.4%). When comparing male and female participants, females were significantly more likely than males to have an NCD (p≤0.011). Females had a higher prevalence of most of the risk factors when compared with males. The urban location had a higher prevalence than the rural location for four risk factors that showed a significant difference between location (p≤0.037). Conclusions Women in Haiti had significantly higher prevalence rates of most NCDs and risk factors than men, and urban populations frequently, but not always, had higher rates of NCDs risk factors than the rural population. Further, it was shown that using point of care blood tests combined with community health workers, it is feasible to screen for NCDs and risk factors in remote areas which otherwise have limited access to healthcare.

Presentation, Treatment, and Outcomes of Haitian Women With Breast Cancer in Miami and Haiti: Disparities in Breast Cancer—A Retrospective Cohort Study

Purpose We compared a cohort of Haitian immigrants with residents in Haiti with breast cancer (BC) to evaluate the effects of location on presentation, treatment, and outcomes. Patients and Methods Participants were Haitian women with BC living in Miami who presented to the University of Miami/Jackson Memorial Hospital and women with BC living in Haiti who presented to the Innovating Health International Women’s Cancer Center. The primary outcome was the relationship between location, cancer characteristics, and survival. The secondary objective was to compare our results with data extracted from the SEER database. Cox regression was used to compare survival. Results One hundred two patients from University of Miami/Jackson Memorial Hospital and 94 patients from Innovating Health International were included. The patients in Haiti, compared with the patients in Miami, were younger (mean age, 50.2 v 53.7 years, respectively; P = .042), presented after a longer duration of symptoms (median, 20 v 3 months, respectively; P < .001), had more advanced stage (44.7% v 25.5% with stage III and 27.6% v 18.6% with stage IV BC, respectively), and had more estrogen receptor (ER) –negative tumors (44.9% v 26.5%, respectively; P = .024). The percentage of women who died was 31.9% in Haiti died compared with 17.6% in Miami. Median survival time was 53.7 months for women in Haiti and was not reached in Miami. The risk of death was higher for women in Haiti versus women in Miami (adjusted hazard ratio, 3.09; P = .0024). Conclusion Women with BC in Haiti experience a significantly worse outcome than immigrants in Miami, which seems to be related to a more advanced stage and younger age at diagnosis, more ER-negative tumors, and lack of timely effective treatments. The differences in age and ER status are not a result of access to care and are unexplained.

Development of a Breast Cancer Treatment Program in Port-au-Prince, Haiti: Experiences From the Field

Purpose The nonprofit Project Medishare launched a breast cancer treatment program in Port-au-Prince in July 2013 to address the demand for breast cancer care in Haiti. We outline the development of the program, highlight specific challenges, and discuss key considerations for others working in global oncology. Methods We reflected on our experiences in the key areas of developing partnerships, building laboratory capacity, conducting medical training, using treatment algorithms, and ensuring access to safe, low-cost chemotherapy drugs. We also critically reviewed our costs and quality measures. Results The program has treated a total of 139 patients with breast cancer with strong adherence to treatment regimens in 85% of patients. In 273 chemotherapy administrations, no serious exposure or adverse safety events were reported by staff. The mortality rate for 94 patients for whom we have complete data was 24% with a median survival time of 53 months. Our outcome data were likely influenced by stage at presentation, with more than half of patients presenting more than 12 months after first noticing a tumor. Future efforts will therefore focus on continuing to improve the level of care, while working with local partners to spread awareness, increase screening, and get more women into care earlier in the course of their disease. Conclusion Our experiences may inform others working to implement protocol-based cancer treatment programs in resource-poor settings and can provide valuable lessons learned for future global oncology efforts.

National Breast Cancer Chemotherapy Program in Haiti

Abstract 19Background:Project Medishare launched a breast cancer program in Port-au-Prince in 2013 at the request of local partners. In 2015, the program was expanded as part of a national breast cancer treatment program with Equal Health International. With the mission of strengthening Haiti’s Ministry of Health (MSPP) cancer care infrastructure, the program seeks to decentralize cancer care for women living up to eight hours driving distance from Port-au-Prince by building hospital capacity for cancer screening, diagnosis, chemotherapy and hormone therapy provision at outlying hospitals.Methods:In 2013, two physicians and three nurses were trained to handle, mix and administer chemotherapy by American nurses and doctors. To expand the national program in January 2015, 20 additional physicians and 32 nurses from all ten geographic regions underwent a three-day training in Port-au-Prince on treatment algorithms and practical training for breast cancer. As patients came in for treatment at the local instit...

Operational implementation and lessons learned from Haiti's first helicopter air ambulance

Critical-care helicopter transport has demonstrated improvements in morbidity and mortality to those patients who utilise the service, but this has largely excluded developing country populations due to set up costs. Haiti Air Ambulance is the first completely publicly-available helicopter ambulance service in a developing country. US standards were adopted for both aviation and aeromedical care in Haiti due to proximity and relationships. In order to implement properly, standards for aviation, critical care, and insurance reimbursement had to be put in place with local authorities. Haiti Air Ambulance worked with the Ministry of Health to author standards for medical procedures, medication usage, and staff training for aeromedical programs in the country. Utilisation criteria for the helicopter were drafted, edited, and constantly updated to ensure the program adapted to the clinical situation while maintaining US standard of care. During the first year, 76 patients were transferred; 13 of whom were children and 3 pregnant women. Three patients were intubated and two required bi-level mask ventilation. Traumatic injury and non-emergency interfacility transfers were the two most common indications for service. More than half of the transfers (54%) originated at one of six hospitals, mostly as a result of highly-involved staff. The program was limited by weather and the lack of weather reporting, radar, visual flight recognition, thus also causing an inability to fly at night. In partnership with the government and other non-governmental organisations, we seek to implement a more robust pre-hospital system in Haiti over the next 12-24 months, including more scene call capabilities.