(posted by Erica Gralla, in Port-au-Prince, Haiti)
Wednesday, Jarrod and I had the opportunity to visit Cange, where Partners in Health (PIH) began its first clinic (see http://www.pih.org/where/Haiti/Haiti.html). To convey just how inspiring that is, Mischa (who has a masters in public health) told us it was like visiting “Mecca” for public health. If you’ve never read Mountains Beyond Mountains, or heard of Paul Farmer, perhaps now is a good time to start.
Jarrod has been working with Partners in Health to examine their supply chain in Haiti, which was already stretched near its limit before the earthquake. Of course, the earthquake changed all that, as donations of money and medical goods poured in faster that PIH could handle them (though the money is never enough for the need in Haiti, it seems), and the supply chain expanded many-fold overnight. Katherine, PIH’s point person for all things logistics, came down to Haiti to assess the situation, lend assistance, and bring Jarrod and I on a logistics-oriented visit to Zanmi Lasante (the Kreyol name for Partners in Health).
My global health friends would perhaps have found our “tour” slightly disappointing – we saw mainly warehouses, boxes, and the storage rooms of pharmacies. For me, this is fascinating stuff – and it should be for you, as well! Because without a steady supply of pharmaceutical products and medical supplies, health systems stop functioning.
Our first stop was Saint Marc, a relatively recent addition to PIH’s network of clinics. The reason for our stop was a brand-new warehouse, built into the back corner of the clinic compound, with gleaming walls and high ceilings. An SUV was pulled up to the entrance, being loaded with boxes for a journey to another clinic. Inside, boxes were piled on boxes, since shelves had not yet been ordered, but the space did not feel particularly crowded (a good thing). Jarrod wanted to measure the warehouse, and since there was no tape measure, he used dollar bills and a camera to get the dimensions of the square floor tiles. This type of making do, ad-hoc creativity is a key element of many supply chains I’ve seen in developing countries. So we fit right in. We saw the paper-based system used to keep stock records, then headed back to the clinic to see the pharmacy. Drugs stocked in the warehouse are sent to the pharmacy weekly (or as needed) to be stored in plastic containers and dispensed to patients. Finally, we wandered the clinic compound a little, while we waited for the driver to pull up the car. Zanmi Lasante pays a lot of attention to landscaping and the environment of the clinic, and in Saint Marc the landscaping was very much in progress. The warehouse was recently constructed, another building was going up near the pharmacy, and trees were being started all over the compound.
Next, we visited the outpatient clinic in Saint Marc, a short drive away. Here we saw another pharmacy, but in this case (perhaps because the main warehouse was not on-site), the pharmacy back room doubled as warehouse. Boxes were stacked to the ceiling, though drugs were organized and accessible. Drugs are dispensed to patients through something like a barred window, though the “bars” are really a nicely worked artistic design.
Finally, we headed toward Cange, the original clinic now grown into a “Sociomedical Complex”, including a full-service hospital, plus blood bank, schools, and other social enterprises. The roads have apparently improved in recent years, and it wasn’t until the last stretch up the side of a mountain (overlooking the lake created by the big dam — if you remember your Mountains Beyond Mountains) that we hit bumpy dirt road. I’ve heard from several people that “there’s Haiti, and then there’s Cange.” I don’t think I can judge the truth of this statement, since my experience of Haiti has mainly been shuttling between the US Embassy and the UN Log Base through a recently destroyed Port-au-Prince. Not exactly the standard Haiti. But I can see why it might be true. Much of Haiti appeared (to my eye) empty and barren, where Cange is covered in tall trees. There’s an atmosphere that I can’t quite put a name to, but it comes from the kids and adults and doctors and managers and everyone else you find in this ‘sociomedical complex’. The school, the hospital, the church, and the koi pond (!) beckoned, but our first stop was… the warehouse!
The “depot” has two floors, with pharmaceutical products stored in the climate-controlled rooms upstairs, and medical supplies downstairs. This warehouse felt distinctly more “seasoned” than the new one in Saint Marc, with a proven system of organization, yet a feeling of being strained almost to its limits. Nevertheless, it functioned well. Most supplies go through Cange, and are distributed from here to the other clinics. Boxes were piled to the ceilings around the outside of the warehouse, waiting for distribution to a clinic when needed, while unboxed medical supplies were stored on shelves for use in Cange. PIH uses an electronic medical records system to track stock. I attempted to learn about it from a very patient woman, using my one-and-a-half semesters of French. Katherine translated where necessary. This time, when Jarrod wanted to measure the warehouse dimensions, someone had a tape measure, so I followed him around writing down dimensions while the PIH staff looked on in bemusement (or, that’s what it seemed to me!).
After our warehouse visit, we got to see the rest of the complex. The hospital is extremely impressive, with two operating rooms, staffed at the moment by a team from the US. We saw women making “Plumpy Nut”, a peanut-based supplemental feeding product aimed at children. We saw the blood bank, patient rooms, an art center run by a woman from North Carolina, and the Friendship House, where guests can stay. Finally, the last stop on our tour: the koi pond! Along the way, we met a number of fascinating and dedicated people who contribute in very different ways to making Zanmi Lasante in general and Cange in particular as amazing as they are.
Our last stop was a PIH agricultural warehouse, which is currently housing some overflow medical goods (donations after the earthquake overwhelmed the dedicated medical warehouses). Finally, we drove back to the hotel. It had been a long, hot day, and we dropped our things off in our rooms, loaded up on bug spray, and headed back to the outdoor tables by the pool, ready for a cold beer. Or so we thought. Katherine asked for one brand, and they didn’t have any. She asked for another, then another, and finally any beer at all. They didn’t have any. At all! They had Bailey’s and vodka and whiskey, but no beer. (And in places where one should be suspicious of ice, beer is really the way to go.) We ordered cokes and lamented. Until, twenty minutes later, someone from another table got up, walked behind the bar, opened the fridge, and pulled out a can that looked suspiciously like beer. We waited to confirm our suspicions; ten minutes later, again. Was the restaurant hiding beer from us? Had they brought their own beer? Was there some sort of misunderstanding? Was this some sort of test, to see whether we wanted beer badly enough to take it ourselves? The suspense was too much. We had to ask. Impolite to say the least, we walked over to the beer-laden table and inquired. Turned out they had brought it themselves. They were also a team from University of Georgia, with a bit of overlap in interests. We exchanged business cards, and they offered us beer. Mission accomplished! (And a good thing too, since we met some interesting people!)
The following morning, we drove back to Port-au-Prince, down a beautiful paved road (it wasn’t always this way). Our last stop was the PIH warehouse in Port-au-Prince, which they acquired just for the earthquake. It’s not a long-term solution, but at the moment it is piled high with all things useful and mysterious. Donations (of goods) after an earthquake are more often useful than not, but sometimes people donate what they have without thinking of what PIH might actually need. This can be a problem if there is limited storage space and limited capacity to look through the donations and understand their use. There were piles of pain relievers and beds and bottled water, but also an entire wall of expired medicines and mysterious surgical equipment no one had the skills to understand. They planned to have a surgeon from the US come down to the warehouse for two full days to sort through the surgical equipment and figure out what might be useful and what to discard.
PIH faces an interesting challenge here. They are generally a health care organization, which has ramped up (amazingly well) to deal with a major emergency in Haiti. How will they manage the assets (donations, warehouses, people) they have acquired for the earthquake when things return to “normal”?