Diary: Trip to Haiti, by Jeevak Lal, MD

1)  Participants and purpose

Dr. Kaz Soong (University of Michigan) and I visited Haiti from April 10 – 17, 2010.   Purpose was two-fold:

i)  To assess the ophthalmologic needs in Haiti after the earthquake and to determine how World Eye Mission (WEM) may be helpful.

ii)  For Kaz to share his anterior segment knowledge and skills with Haitian colleagues.

2)  Travel

Kaz and I met at Miami Airport and took the afternoon American Airlines flight to Port au Prince.

Soon after exiting the aircraft in Port au Prince, we were met by an airport official.  Dr. Jean-Claude Cadet, the director of the eye residency program in Port au Prince, had arranged this unexpected courtesy.  The officer escorted us through immigration and customs.  Dr. Cadet came into the restricted customs area and welcomed us!

Dr. Jean-Claude Cadet is a respected ophthalmologist.  His father was an ophthalmologist who had earlier directed the residency program.  I had briefly met the senior Dr. Cadet when I was in Haiti as a resident on a surgical rotation in 1981.  Dr. Jean-Claude’s son, Jean-Claude Jr., is an ophthalmologist as well!  ‘Junior,’ was also at the airport.  Father and son are soft-spoken gentlemen.

3)  Accommodation

The doctors Cadet drove us to our hotel, La Plaza.  It is one of three now open in Port au Prince.  In 1981 it was the Holiday Inn.  Kaz and I shared a room.  The hotel is comfortable, with its own water supply, generator and air-conditioning.  But the latter was only available at night.  Meals in the restaurant were well prepared and very adequate.  But we were selective in what we ate, preferring to avoid uncooked items.  Bottled drinking was readily available.  As protection, we were both immunized against Hepatitis A and B and were taking malaria prophylaxis. 

4)  Port au Prince

The drive to the hotel through the city was sobering.  There is no need to elaborate.  You are familiar with the scenes of destruction.  The city has been brutally hurt.  But the people are not lamenting, nor wailing.  They are not asking, “why us?”  They have accepted their fate and the hand dealt to them.  They are on the move.  They are walking tall and straight.  They will endure. 

5)  Schedule/activities/facilities

On our first full day, Sunday April 11th, we had opportunities to meet several Haitian ophthalmologists and their families.  Their hospitality and expressions of appreciation at our visiting Haiti were heart-warming.  They told us that most had suffered damage to equipment in their offices.  Additionally, with more than a million people now without work and income, their practices were suffering losses.   Patients were seeking care at the publically funded University Hospital.  This situation was creating a heavy workload for the residents and staff of the residency program.

Later that afternoon we visited the University of Miami’s field hospital at the airport.  It is a remarkable tent facility, staffed by innumerable doctors, nurses, para-medics and lay supporters from the United States.  Kaz had worked there ten days after the quake.  He let them know he was in town for the week and was available for consultations.

The work began in earnest on Monday, April 12 and continued through the week till our departure on Saturday, April 17.

The routine was for us to be picked-up at the hotel by either of the Drs. Cadet or Dr. Reginald Taverne and driven to the University Hospital’s eye clinic.  Dr. Taverne is an accomplished ophthalmologist in private practice.  He has a large patient-base and a well equipped office.  Some of his equipment had been damaged during the quake.  Kaz has a background in electrical engineering and was able to fix some of Reginald’s pieces!  Kaz’s prowess in this area had him busy trying to fix damaged items at the University Hospital as well.  I will discuss this critical issue a little later in the report.

The eye clinic was built about twelve years ago with support from Lions International and the Chistoffel-Blindenmission.  It is airy and simple.  It has sustained some damage  but the operating room and examination rooms are functioning.  The daily patient load is now in excess of 150 visits and rising.    The clinic is staffed by four residents (one senior, two second year and one first year).  One resident left the program after the quake.  An attending is present during clinic hours and for surgery.  The residents provide call for emergencies.

Patients had been pre-selected for our visit and constituted a vast mix of anterior segment pathology.  We were concerned by the significant numbers of patients with corneal pathology who might benefit from corneal transplants.  How to achieve that goal is a major problem and bears discussion by our anterior segment professors.

Cases were presented by the four residents.  Diagnostic and management aspects were discussed in detail.  The residents understood and spoke English, although their spoken vocabulary was, at times, a bit hesitant. The junior residents were somewhat shy about asking questions. 

Surgeries were performed in the early afternoon.  Cases were selected for surgery on the basis of their suitability for skill-transfers.  In earlier discussions with Dr. Cadet, it had been decided not to perform any major intra-ocular procedures at this first visit. Accordingly, the procedures were conjunctival autografts for pterygia, corneal perforation gluing, an orbital tumor biopsy and assisting the residents with cataract surgery (extra caps.)   It was our impression that the residents had good surgical skills.  They were receptive to suggestions for refining their techniques.

The surgical instruments were usable but of marginal quality.  They need to be replaced.  The Zeiss operating microscope lacked foot controls and had to be manipulated manually. There was a second microscope but I am not sure if it was functioning.

The residency program has weaknesses.  For instance, it is heavily involved with anterior segment work.  Deeper eye pathology is inadequately managed.  They do not have a retinal laser or fluorescein angiography.  I am not sure if they even have an indirect ophthalmoscope.  But they do have a YAG. 

Another issue that concerned us was their reluctance to perform refractions.  We were constantly seeing patients with only uncorrected visual acuities recorded.  Kaz and I clearly expressed our concerns about this issue and demonstrated the ease with which, at least, pin-hole acuities could be determined.  The importance of refractions was impressed upon them.  The residents appeared not to have much experience in performing this critical assessment.  I offered to return and run a concentrated course on basic linear optics and refraction.   They accepted this offer and I will try to visit later this year or early in 2011. 

Despite its nominal flaws, the residency program serves a central role in caring for the poor.  I believe it is crucial that WEM not be discouraged by the shortcomings.  They are correctable. We must not abandon them.  Rather, we need to buttress them through a period of unimaginable grief.  While we are ecstatic about our ties to the strong programs in Peru and Guatemala, it is far more important for us to help our Haitian colleagues sustain and develop their program.  The future of Haitian ophthalmology, to a large degree, lies in the residency program.  If it collapses, so might the training of future Haitian ophthalmologists.

Dr. Cadet wants us to send more visiting professors of all sub-specialties.  He feels his program can handle about six visitors annually and each should visit for at least one week.  He also requests a lead time of about six weeks to recruit suitable patients.  Please note that the hosts have to commit much time and effort in preparing for a visitor

Late in the afternoons and running into the evenings, Kaz delivered several lectures on anterior segment conditions.   These were attended by the residents, faculty and several private practitioners.  The lectures were frequently interrupted by penetrating questions, and vigorous debate.  This inter-action was stimulating.

6)  Peripheral eye clinics

Many public eye clinics on the outskirts of Port au Prince are in ruin.  Some of these were staffed weekly by Dr. Cadet and his team.  I visited one.  The building is rubble.  The clinic is now based in a nearby tent city.  It is covered with a tarpaulin.  There are a few chairs, a box of lenses, an acuity chart and an ophthalmoscope.  A technician does crude refractions (omitting the cylinder correction) and prescribes approximate spherical equivalents.  Patients suspected of pathology are referred to the University Hospital’s eye clinic. 

7)  Damaged equipment

We were concerned about the damage inflicted upon ophthalmic equipment by the quake.  Several slit-lamps in the eye clinic have been damaged.  Private practitioners report extensive damage to their instruments as well.  Some have lost all their equipment.  They have contacted the manufacturers and their agents/distributors in the United States.  Almost all want the damaged equipment shipped to the mainland.  This would be very expensive.  It might be better if repair technicians could visit Haiti, assess what is salvageable and perform some on-site repairs.  Kaz may approach the American Academy of Ophthalmology with this suggestion.

8)  Safety

There are many who fear going to Haiti because of personal safety concerns.  For them I have but two words, “fear not.”   Our Haitian hosts were ever attendant to our needs, were with us constantly and showered us with overwhelming affection.  And more importantly, this affection was reflected in the genuine, heart-warming gratitude of the many, many patients we were privileged to meet.

9)  Recommendations

WEM Board has agreed to support a visiting professor program in Haiti.   Our Haitian colleagues are requesting it.  We have long-established and very warm ties withophthalmologists in the country.  We are in an ideal position to be of service.  I most strongly urge that we do so.

Haitian ophthalmology has taken a huge hit.  But they are not out.  They are shaken but standing.  They are caring for their patients. We must remain in their corner.   

Patrick Commiskey