New Haiti orthopedic surgery residency rotation and education exchange provides bi-directional training opportunities

You do not need to look beyond the western hemisphere for stories of national resilience in the developing world. Rudolph Richeme, M.D. provided an appropriately timed overview of the state of healthcare in Haiti and the unwavering resilience of its people during a lecture as part of a residency rotation and exchange program directed by the South Carolina Orthopedic Association, the Medical University of South Carolina’s (MUSC) Department of Orthopedics and Hopital de la Paix, one of two teaching hospitals in Port-au-Prince. Richeme was accompanied by Dr. Thony Gillaume as they presented at an event co-sponsored by MUSC Center for Global Health, Department of Orthopaedics, Charleston County Medical Society, and the Charleston Orthopaedic Society.

Richeme is a Haitian-born orthopedic surgery resident at Hopital de la Paix. He has received medical and surgical training in Haiti and abroad from renowned healthcare professionals. He served as medical director at Hopital Lumiere in Bonne Fin, Haiti for several years after the 2010 earthquake. Now he is pursuing his dream of orthopedics. Working with US physicians, such as Shane Woolf, M.D., Associate Professor of Orthopaedics and Chief of Sports Medicine, Richeme has been afforded opportunities to see healthcare from two very different worlds. Richeme’s skills and training are applicable across borders and highly valuable. He chooses to remain in Haiti where healthcare conditions can worsen to epidemic proportions overnight, compensation is uncertain and corruption constrains resources.

“A lot of health professionals have left Haiti for better pay and conditions,” explained Richeme. “My belief is that more hands make a lighter burden. This is the only way to solve issues weighing down Haiti’s healthcare system.”

Richeme has just cause to tire of the healthcare system in his home country. However, he doesn’t. Prior to the 2010 earthquake, Richeme treated patients with only meager resources at his disposal. The work he led was not only laborious, but he could not sufficiently treat minor conditions due to a lack of supplies. Even compensation was hard to come by. His employer could not pay healthcare workers for six months. “After six months, we did not think we were going to be paid,” Richeme remarked. “We were unsure if vital staff would stay around since they were not paid either.”

Richeme was notified a year later about receiving a paltry two months’ worth of income. Overwrought with delight, Richeme and his wife were en route to Port-au-Prince to pick up his pay when the earthquake hit registering a five on the Richter scale near Bonne Fin. In Port-au-Prince, the quake registered as high as 7.3. Nonpayment no longer consumed Richeme’s thoughts—it was the safety of his son back in Bonne Fin.

Healthcare facilities were expectedly overcrowded: more than 1500 patients waited to be seen in a 120-bed hospital. And without the quake, Richeme’s employers were to soon close their doors. Medical disaster response teams from around the world deployed to Haiti in an effort to assist with the damage. Among them were Woolf and a team from MUSC. “Without these teams responding and seemingly running the hospitals, most of them would have had to close their doors,” said Richeme.

From that point, a group of orthopedic surgeons and state partners including Woolf committed a substantial portion of their time to sustainably developing a program that trains surgeons like Richeme and his colleagues. The South Carolina Orthopedic Association created a mechanism in the Haiti Global Orthopedic Resident Education Initiative to provide rigorous, bidirectional training for American and Haitian surgery residents.

“This unique collaboration among MUSC, USC, Greenville and the Hopital de la Paix orthopedic departments allows for cross-cultural orthopedic education, experience with complex pathology and injury patterns, exposure of the visiting Haitian residents to ACGME accredited training programs and their structure, as well as alternative surgical and non-operative treatment experiences for our trainees,” explained Woolf.

Woolf thought it important to, at the very least, preserve the balance of well-trained Haitian-born orthopedic specialists considering the ratio of surgeons and patients in the country. His hopes are to increase that number and provide trainees from both the US and Haiti with exposure and training in vastly different healthcare systems. “The other important benefit is continuity of care for patients treated in Bonne Fin by the visiting teams, with a visiting group from South Carolina in country every two months,” Woolf said. “The education of future Haitian medical professionals, continuity of orthopedic care, and elevating the standard of medical and orthopedic care in the very same hospital our six teams visited after the earthquake five years ago is the result of a large group effort among the Lumiere staff and administration, the South Carolina Orthopedic Association and residency programs, and several very dedicated individuals, including Dr. Robert and Anne Belding.”

Facing humanity
On the tiny island of Hispanola lie two nations: Haiti and Dominican Republic. The world does not need convincing of the conditions in Haiti—mostly due to anthropogenic influences and corruption that have manifested off and on for decades. Interestingly, the two countries have substantially different economies as classified by the World Bank. Dominican Republic is considered an upper-middle-income economy with a gross national income (GNI) between $4,126 and $12,735. Haiti, having a slightly smaller portion of the shared landmass, is a low-income economy having a GNI of $1,045 or less.

Accurate data is not available to detail the ratio of physicians to patients, which is telling. Richeme explained that there are eleven orthopedic specialists for 3 million Haitians who seek their services. Non-Haitians have historically provided needed care across the countryside. Given the confluence of problems that led to medical and security risks presently plaguing Haiti, Richeme remains optimistic that the era of malfeasance and government ineptitude is winding down. “We have an opportunity now to open people’s minds,” said Richeme. “It is less about existing problems and more about actionable solutions through programs like the rotation and personnel exchange.” Richeme has seen systems fail needlessly. When his brother was completing medical school, he was denied what would have been life-saving care due to visa processing backlogs and increasingly exorbitant fees. He later died of liver cirrhosis.

Richeme came face-to-face with humanity again when he later witnessed the devastation the earthquake would cause in the immediate aftermath. Death and destruction were and remain widespread. Now, explained Richeme, cholera and chikungunya ravage areas where rain, and subsequently mosquitoes have come earlier than usual. The compounding of public health problems is difficult to juggle for any nation, even those with GNIs orders of magnitude larger than Haiti’s. Still, Richeme finds the strength to continue working for his people. “Life is not a piece of cake,” said Richeme. “We are going to have a lot of language barriers; we will have ethnic, cultural, and economic barriers. But you have to see the humanity in what we do as healthcare professionals. We all are different and we should get over it to best serve our patients.”

Richeme once again faced humanity on his trip to present in front of a group of orthopedic surgeons at MUSC. He is a man anchored by faith in the choppy, white-capped seas of his existence: faith in the good of man and his God. In all of Richeme’s travels, the cases of rare diseases—and common, treatable ones—left untreated; the abject poverty in his country; and the adversity he has seen his own family rebound from, he was struck by the response Charleston, SC had in recent months to its own embracing of humanity.

What he observed during his visit to Mother Emanuel Church reinforced his belief that good triumphs. Contrary to assumed callousness and indifference saw in higher-income countries, Richeme saw redeeming resilience and compassion of people from all backgrounds during his visit. This, he said, is the unity we are supposed to live in every day—not just during a natural disaster or act of inhumanity. “We are living in a broken world,” said Richeme. “And as a surgeon, we look for those broken ends to touch; we try to adjust the malalignment; we recalibrate an off rotation. It is the same with situations we face. In order to remain stable, we must embrace our similarities.”