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mardi 3 août 2010

In Haiti, a Lesson for U.S. Health Care

By JAMES WILENTZ
Published: July 28, 2010
In February, a month after Haiti’s earthquake, I went down to Port-au-Prince as part of a team that was helping to reactivate cardiac care in the city’s public hospital. For several months since, I have observed how the earthquake and its aftermath profoundly changed Haiti’s health care system. Over that time, I have come to the unorthodox conclusion that Haiti’s tragic experience may show us a way to improve health care in the United States.
Let me explain. The sudden availability in Haiti of free high-quality care from foreign doctors put enormous competitive pressure on the private local doctors, who had already been working under difficult conditions. Watching this situation unfold, I found myself wondering if the same would happen to private medical services back in the United States were our government to suddenly provide high-quality, low-cost health care.
Haiti, with the worst health care record in the Western Hemisphere — the infant mortality rate is nine times that of the United States and the maternal mortality rate is 50 times as high — was ill prepared to help disaster victims. For the public hospital in Port-au-Prince, earthquake damage only made things worse. Into this vacuum surged hundreds of international doctors and nongovernmental health care organizations.
In the beginning, of course, those with immediate injuries were treated first. But even after the earthquake victims had been taken care of, lines more than a quarter-mile long still formed at the hospital entrance. There were mothers carrying babies with swollen bellies, prematurely old men and women with waterlogged legs and labored breathing, people with painful sores and lots of people coughing. These were Haitians who’d had no access to medical care in a long time and who suddenly saw hope in a hospital full of foreign doctors eager to help at no charge.
This humanitarian aid came with a downside though: it caused many of Haiti’s local private clinics to lose business. One such clinic is Michel Théard’s cardiac practice, near the public hospital where I worked. Before the earthquake and during the immediate aftermath, Dr. Théard did echocardiograms (ultrasound images of the beating heart) for cardiac patients, because the public hospital lacks the equipment to do them. His ultrasound pictures, and those done by other private Haitian cardiologists, often at charity rates, enabled us to diagnose many conditions for patients in the public hospital.
But because Dr. Théard, and the private hospital with which he is affiliated, cannot compete with free foreign doctors, there is a danger that he will no longer be able to stay in business and provide echocardiograms for the poor.
There are many other services that only private doctors provide in Haiti, because the public hospitals are so poorly financed. The rudimentary intensive care unit at the public hospital has no heart monitors, oxygen sensors or any other kind of modern medical equipment. The only thing “intensive” about the I.C.U. is that a health care worker (doctor, nurse or nurse-anesthetist) is present at all times. A CT scanner donated to the hospital in the early ’90s lies rusting outside one of the buildings, sad evidence of the public medical system’s failure to provide adequate care.
Patients who can afford it get specialized procedures like CT scans and echocardiograms at private clinics and then return to the public hospitals for free care. This is also the case for many medicines: family members buy them at a pharmacy and bring them back to be kept under the patient’s hospital pillow for dispensing at the prescribed times.
Perversely, by shoring up the capacity of the normally dysfunctional public health system during this crisis, the foreign doctors may be further damaging Haiti’s fragile medical sector. Once they leave, who will be left with the will and the capital to adequately care for Haitians?
James Wilentz is a cardiologist at the Lenox Hill Heart and Vascular Institute.
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A Font of Ideas From a ‘Nomadic’ Humanitarian Architect

This time last week, Nathaniel Corum was on a Navajo reservation in Arizona where three elders’ families were moving into new solar-powered homes that he’d designed to be built from straw bales. Next came the news that the Plastiki, a boat made from 12,500 recycled plastic bottles for which he’d designed the cabin, had docked safely in Sydney after a 130-day voyage across the Pacific to protest against plastic waste.
Matthew Grey
Nathaniel Corum, a designer for Architecture for Humanity, in the Plastiki, a boat made from 12,500 recycled plastic bottles, for which he designed the cabin.An earlier version of this caption misstated Nathaniel Corum’s role in the Plastiki’s design.

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The Plastiki crew
Exterior of the Plastiki cabin.
Nathaniel Corum
A Navajo solar straw bale home in Arizona, designed by Mr. Corum.
He’s starting this week in San Francisco, where he is helping Architecture for Humanity, the volunteer network, to plan a reconstruction program in Haiti. Now 43, Mr. Corum has worked on humanitarian design projects like these for a decade, helping people living on the margins of society, such as the Navajo elders, or those whose lives have been shattered by the Haiti earthquakeand other disasters.
He doesn’t have a partner, kids or even a home in the conventional sense. “AfH is my hub,” he explained. “I have a place in the Bay Area, but I consider myself nomadic.” Traveling from place to place, he communicates with collaborators, family and friends on social networking sites and on AfH’s Open Architecture Network from a portable workstation containing a military standard computer, which is waterproof, shockproof and so crush proof that a car could drive over it.
An obscure field when he joined it, humanitarian design is now one of the most dynamic — and controversial — areas of design. Bruce Nussbaum, an influential American design commentator, recently posted a blog entitled: “Is humanitarian design the new imperialism?” in which he accused some humanitarian designers of imposing well-meant, but inappropriate solutions on developing countries.
Unsurprisingly, Mr. Corum rebuffs the charge. “The richer the dialogue you have with the people you’re working with the better,” he said. “I spend lots of time with them, and learn so much, especially from people living close to the land. Humanitarian design isn’t the new imperialism, it’s the new compassion.”
Born in Boston, and raised in Vermont, he studied product design at Stanford University, then went into commercial design. “I worked with some great firms, but found we were shopping for gold-plated fixtures,” he recalled. “I felt like a personal shopper or glorified manicurist. The work wasn’t as meaningful as I wanted it to be.”
What he wanted was to experiment with the sustainable lifestyle he’d experienced as child living on a farm in Vermont with his English professor father and social worker mother. After taking an architecture degree at the University of Texas, he won a Fulbright Scholarship to research in Morocco, where he spent time with Berber tribal groups. Returning to the United States, he worked with tribal groups in Montana and North Dakota on a Rose Architectural Fellowship, and experimented with building homes for them from straw bales, compressed sunflower seeds and other local materials.
He also taught at Montana State University, where he met Cameron Sinclair and Kate Stohr, the co-founders of AfH. “They were taking a year out in the mountains to write a book, and bumped into me when they were recruiting students as volunteers,” he recalled. “When they set up AfH’s office in the Bay Area, I was finished with my fellowship, so I went with them.”
While they expanded AfH’s volunteer network, which now includes 40,000 architects, designers and engineers, and raised funding for its projects, Mr. Corum developed the education program and continued his experiments with sustainable housing by working with Navajo elders in New Mexico and Arizona.
He also participated in AfH design projects, including the work on the Plastiki cabin. “David came to the office to see Cameron in early 2008,” he recalled, referring to David de Rothschild, the expedition leader. “I’d been doing a rafting trip, a floating classroom in the Grand Canyon, so we had this boat thing to talk about. We went out for a curry and hatched this idea that AfH could work on a shelter and communications hub to sit on the catamaran, which would be a useful model for our other projects.”
This time last year, Mr. Corum was in Arizona working on the Navajo homes. By early fall, much of his time was taken up by the Plastiki, for which he was cabin architect and sustainability consultant. The cabin design was finessed throughout the construction process as the Plastiki team learned more about how the specially developed form of srPET, the plastic used in water bottles, would respond to the voyage. “We also relocated the portholes and ventilators to give good ambient light throughout the cabin, but so the crew would take naps in daytime after crazy 20 hour shifts,” he said. “And my friend, Paul Giacomantonio, put a very sophisticated vegetable garden on board.”
By mid-December, the Plastiki was completed, and Mr. Corum joined one of its first voyages in San Francisco Bay. Much of the winter and spring was spent running student workshops in the United States, Australia and New Zealand for the Pacific Rim Studio, an AfH program linked to the Plastiki. He’d planned to join the boat in Hawaii after a workshop there in May, but it was blown south and stopped at Easter Island instead, so he returned to San Francisco.
Since then, he has worked on more Navajo homes in Arizona and New Mexico, and a new series of student workshops on indigenous architecture, which will succeed the Pacific Rim Studio. As part of AfH’s reconstruction program in Haiti, he is also collaborating with scientists and engineers on developing environmentally responsible ways of recycling concrete to use there.
“Up until this point, I’ve been a little bit religious about using natural materials, but figuring out how to use plastic for the Plastiki got me thinking about being less picky and working with whatever’s available,” he said. “It’s a question of looking at what’s piling up around you, in the ocean it’s plastic, and in Haiti it’s concrete. We’re discussing options now, but when the right eco-concrete build project comes along in Haiti, I’d be keen to get down there.”http://www.nytimes.com/2010/08/02/arts/design/02iht-design2.html?_r=1&ref=haiti

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