Moral Responsibility in a Context of Scarcity: the Journey of a Haitian Physician

Almost all Haitian physicians have been involved in some sort of "social movement" at one point in their professional life. In a country characterized by a natural inclination to question authority, fighting the status quo of the ineffective, corrupt and disorganized Haitian health system often appears to be the right thing to do.

In 2002, I played an active role in a large protest movement for better working conditions at the largest health facility in Port-au-Prince: the General Hospital (GH). Port-au-Prince is the capital and economic center of Haiti. It is home to close to a third of Haiti's ten million people. At that time, the situation at the GH facility was dire. All of the 400 beds at the GH were dirty. The staff was underpaid and unhappy. Drug and medical supply stock-outs were routine. Medical equipment was rarely maintained and only one of the six operating theatres in the surgery block was working. Unsupervised physicians in training (like me) were the main health care providers. Attending physicians were busy running their own private clinics, and most of them would come to the hospital solely to "recruit" the less poor patients for their clinics. As physicians-in-training, we had the responsibility of caring for the poor, but we had no means. We grew frustrated and angry witnessing our powerless patients losing legs, arms and their lives for lack of care. On many occasions, I had the parents of my patients buy the gloves that I would use to examine their sick relatives. I've seen patients fighting for the inheritance of medications left by others who had just passed away. There was no way for this hospital to fulfill its mission, and no way for its staff to deliver anything other than mediocre care. We could not accept that situation at such an early stage in our medical development, and so we refused to continue to work. We went on a strike, which completely paralyzed the delivery of care at the hospital for nearly two months. After intense negotiation, the strike ended with a signed agreement with the Minister of Health that addressed, more or less, the reasons of our movement. However, the implementation of the agreement was permanently delayed by other competing "state emergencies" including a general insurrection.

At the time of our movement, I thought we were making history. After witnessing 11 "social movements" that similarly paralyzed the GH in the following decade for reasons identical to ours, I am now convinced that we were not. We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince. The social movement that we started ended up hurting the very same people that we were trying to help.

Extending access to heath care to poor people seemed to me at that time to be too complicated and too expensive for an unorganized state like Haiti. I realized that local protests could, at best, influence the allocation of local resources. But so-called local resources are so limited in "resource-limited" countries. Haiti spends only $40 U.S. dollars per capita for health care. This is not enough for good care. The options we were provided were not real ones—since all of them would end in more suffering. The case of providing health care to poor people needed to be approached differently.

I was born in Port-au-Prince at the same general hospital in which I would later work. I am the third of four children, and the first male child in my family. My father made me understand very clearly that my first responsibility was for my siblings. My sisters made me understand equally clearly that I had no authority over any of them. I ended up with a lot of responsibility but with very little authority. The few of us who completed school, entered university, studied abroad and "emerged" were considered, to some extent, responsible for the others—the ones who couldn't go to school, university, or abroad, the ones who had "sunk...