Anyone who has worked on the ground in a resource poor setting quickly realizes that bad things happen (even in noble quests), and yet accounts of failure may fall on deaf ears of colleagues and supervisors alike because they're viewed as unsavory. Unlike prevailing academic medical tradition where morbidity and mortality conference plays an important role in education, and more importantly in preventing future adverse events – I have found that few feedback loops exist for healthcare providers working in resource poor settings. Oft cited reasons include cultural inappropriateness of such exercises as well as the 'politics' involved. Yet, by avoiding all discussion of what went wrong we are vastly underestimating the professionalism of our local colleagues, and are also magnificently failing our patients.
The vital need for honest self-policing and assessment aside, it has also become apparent that writing originating from some corners has become one sided and essentially propaganda of their own self importance. Clearly if the entire field of global health was so successful, we would not still be battling plagues long after effective cures were discovered. Much like negative clinical trials in the medical literature, I've found that most accounts of how consistently we fail our patients will not be published unless there is an accompanying silver lining or morale boosting lesson. Undoubtedly this stems from a fear that donors will be repelled by anything short of an inspirational seven minute speech accompanied by a neat slide-show. Since we are in the practice of medicine and not in the field of marketing, in addition to trumpeting our successes we also have a duty to report the horrific scenarios our patients repeatedly face due to inadequate diagnostics, supplies, and staff – and to push for change.
As if this neglect wasn't bad enough, it seems that more and more global health and development conferences these days seem to revolve around underlining hyped-up successes (often by professional circuit speakers), rather than the forging of real alliances between the different actors to enact change. True cooperation between those involved in health care delivery in resource limited settings may ultimately reduce waste, prevent duplication of efforts, and increase activity in areas of neglect. Instead, many of us seem to be constantly reinventing the wheel. Cooperation needs to be grounded on the level of local governments, people and organizations based in the places we serve, rather than trying to circumvent them – as 100 years from now when outside interests may have shifted the locals will remain.
Perhaps the reason there is a fundamental absence of cooperation is that increasingly organizations are fueled by greed (whether NGOs, foundations, universities or social entrepreneurs). Rather than profit, they compete for influence; desiring their brand stamped over people, product and infrastructure. Sometimes this is even at the cost of inferior care – so long as another organization is not “in charge.” Haiti is the perfect example of a situation where despite a relatively small population (10 million) and billions of dollars being poured in since the 2010 earthquake (through a disproportionately large number of organizations), we see few improvements in health or socio-economic indicators. Organizations here do simply do not talk to each other. They exist in their own putrid bubbles, often a stone's throw away from similar (if not identical) organizations. They do not share resources, they don't discuss strategy or goals, they just do. What they precisely do is often unclear– especially to the government / ministry of health – who are held prisoner to extremely limited resources and thus unable to enact meaningful health policy independently.
Despite my cynicism, laudable work is being done by a small number. Some groups exclusively employ Haitians to positions of leadership so that they may shape their country's future and are not dependent on the interest of outsiders. Other organizations have expanded their focus from purely medical delivery to fighting for adequate food, water, sanitation and housing – desperately trying to convince others (of the seemingly not-so-obvious reality) that all are interrelated. A select few refuse to accept the dogma that high quality care cannot be afforded to those most endangered in low resource settings and have taken arduous steps to ensure state-of-the-art facilities and training of local providers to match. For those working in Haiti for the long haul it seems a constant struggle to maintain funding streams to ensure that vital life sustaining work can continue once the reporters and cameras have departed. As I continue medical work in Haiti, my sincere hope is to see more honesty and cooperation between all organizations here – the present isolated path followed by some is not only unsustainable but also a disservice to our patients.